Podium Session 1: Prostate Cancer June 26, 2016 1050–1150

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S3.

POD-01.01: Efficacy and safety of enzalutamide versus bicalutamide in younger and older patients with metastatic castration-resistant prostate cancer in the TERRAIN trial

D Robert Siemens ¹, H Laurence Klotz ², Axel Heidenreich ³, Simon Chowdhury ⁴, Arnauld Villers ⁵, Benoit Baron ⁶, Steve van Os ⁶, Nahla Hasabou ⁷, Fong Wang ⁸, David Forer ⁸, Neal D Shore ⁹

Abstract

Introduction and Objectives:

The phase 2 TERRAIN trial compared the efficacy and safety of enzalutamide (ENZA) vs. bicalutamide (BIC) in patients (pts) with metastatic castration-resistant prostate cancer who had progressed on luteinizing hormone-releasing hormone agonist/antagonist therapy or after bilateral orchiectomy while maintaining castration therapy during the study. An age effect analysis was pre-specified to investigate the efficacy and safety of ENZA vs. BIC. Results are presented in younger (<75 years) and older (≥75 years) pts in the TERRAIN population.

Methods:

In this double-blind study in North America and Europe, pts were randomized 1:1 to ENZA 160 mg/day or BIC 50 mg/day. The primary efficacy endpoint was centrally assessed progression-free survival (PFS) and a secondary efficacy endpoint was time to prostate-specific antigen (PSA) progression.

Results:

184 pts were randomized to ENZA and 191 pts to BIC. 126 (68.5%) and 119 (62.3%) pts were <75, and 58 (31.5%) and 72 (37.7%) pts were ≥75, in the ENZA and BIC arms, respectively. PFS was significantly improved with ENZA vs. BIC in pts <75 years (median 16.6 vs. 5.8 months; HR 0.38 (95% CI 0.27, 0.52) and pts ≥75 years (median 13.8 vs. 6.4 months; HR 0.59 (95% CI 0.37, 0.92). Median time to PSA progression was similarly significantly improved with ENZA vs. BIC in younger (median 22.1 vs. 8.2 months; HR 0.27 (95% CI 0.18, 0.40) and older pts (median 16.6 vs. 5.8 months; HR 0.33 (95% CI 0.19, 0.57). Adverse events (AEs) with ENZA were more frequent in older pts (98.3%) vs. younger pts (92.8%), but a similar distribution of treatment-related AEs between treatment arms was observed in either age group.

Conclusions:

ENZA had greater efficacy than BIC regardless of age, with superior PFS and time to PSA progression. ENZA showed safety consistent with its known safety profile in both age subgroups.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S3–S4.

POD-01.02: A pan-Canadian contemporary analysis of active surveillance uptake for low-risk, localized prostate cancer in Canada

Narhari Timilshina ¹, Veronique Ouellet ², Shabbir M Alibhai ¹, Anne-Marie Mes-Masson ², Nathalie Delvoye ², Darrel E Drachenberg ³, Antonio Finelli ¹, Marie-Paule Jammal ⁴, Pierre Karakiewicz ², Hélène Lapointe ³, Jean-Baptiste Lattouf ², Kenny Lynch ⁵, Jean Benoit Paradis ⁶, Paula Sitarik ³, Alan I So ⁵, Fred Saad ²

Abstract

Introduction and Objectives:

In active surveillance (AS), practitioners delay curative treatment in low-risk patients until there is evidence of disease progression, at which time active treatment is initiated. Although the uptake of AS appears to be increasing, the actual uptake in Canada remains largely unknown. The aim of this study is to examine practice patterns around the use of AS in low-risk prostate cancer in Canada. In addition, we examined regional variations in uptake of AS, as well as predictors of AS uptake and persistent use of AS for 12 months.

Methods:

We evaluated the use of AS in men who underwent a prostate biopsy in 2010 in six centres in four provinces (BC, QC, MB, and ON). For incident cases, clinical and pathological information was collected via chart review prospectively for 12 months following the last biopsy of 2010. Eligibility for AS and treatment trends by region were compared using chi-square tests for categorical variables and the ANOVA test for continuous variables. Univariate and multivariate logistic regression was used to examine predictors of choosing AS upfront (versus active treatment within six months of diagnosis) and to predict the likelihood of continuing on AS for 12 months.

Results:

Of 986 patients, 781 patients (mean age 64 years) were incident cases and were eligible for AS. Over three-quarters (77.3%) of patients chose AS at diagnosis. There were significant differences in uptake of AS by region (range 65.0–98.0%; p≤ 0.05). Key multivariate predictors of pursuing AS included age (p=0.044), region (p=0.021), number of cores (p=0.025), number of positive biopsy cores (p<0.001), and percent core involvement (p<0.001). 516 (85.4%) men remained on AS over 12 months. Maintenance with AS over 12 months differed by region, ranging from 64.1–93.9% (p=0.001). Predictors of maintenance with AS over 12 months included age, region, and number of positive cores. In all, 177 (22.7%) patients eligible for AS underwent an active treatment within six months from diagnosis. Among 604 patients who underwent AS for at least six months, 88 (14.6%) received active treatment within 6–12 months after AS.

Conclusions:

These results suggest that AS is widely practiced across Canada and the majority of men who choose AS remain on it for 12 months, although there are significant differences in practice patterns between and within provinces. More in-depth analyses will be required to understand the root causes of these differences, and also to determine whether AS uptake is changing over time.

Fig. 1. — POD-01.02. Distribution of incident patients by initial active surveillance (AS) vs. upfront active treatment.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S4.

POD-01.03: The burden of symptomatic skeletal events in castrate-resistant prostate cancer patients with bone metastases at three Canadian uro-oncology centres

Fred Saad ¹, Neil E Fleshner ², Alan I So ³, Jacques Le Lorier ¹, Louise Perrault ⁴, Melanie Poulin-Costello ⁵, Raina Rogoza ⁵, Ewan JD Robson ⁵

Abstract

Introduction and Objectives:

Castrate-resistant prostate cancer (CRPC) patients (pts) with metastatic bone disease (MBD) risk significant morbidity, including symptomatic skeletal events (SSEs) (palliative radiation, pathological fracture, surgery to bone, and spinal cord compression), and require substantial healthcare resource use (HRU). We estimated MBD-related HRU costs at three Canadian (Cdn) uro-oncology centres (UOCs).

Methods:

A retrospective chart review conducted at Centre hospitalier de l’Université de Montréal (CHUM), Princess Margaret Cancer Centre (PMCC), and Vancouver General Hospital (VGH) estimated MBD-related HRU costs between MBD onset and death in pts dying from or palliated for metastatic CRPC between Jan. 1, 2006 and Jan. 31, 2013. Patterns of SSEs and bone-targeted therapy (BTT) use were analyzed.

Results:

393 pts (CHUM (130), PMCC (154), VGH (109)) were enrolled, with a mean age of 71 years (yrs) at MBD onset. Median survival from MBD onset was 23.9 months (mos) (no significant difference between sites). 275 (70%) pts experienced 833 SSEs (85 events per 100 pt yrs). Median time to first SSE was 17.6 mos. Pts presented a mean of 2.12 SSEs. Mean MBD-related HRU costs were $31 827 for pts with ≥1 SSE and $14 092 for pts with no SSEs (2014 CAD). 201 (51%) pts received ≥1 BTT, mainly zoledronic acid (ZA) (190/201 (95%)). Median (95% CI) time (mos) to first SSE was longer at CHUM vs. PMCC or VGH (25.0 (18.5–32.6) vs. 14.6 (9.7–16.8) or 17.3 (14.8–24.0)). Fewer pts at CHUM experienced ≥1 SSE vs. PMCC or VGH (71/130 (55%) vs. 121/154 (79%) and 83/109 (76%)). More pts received BTT at CHUM and PMCC than at VGH (83/130 (64%) and 92/154 (60%) vs. 26/109 (24%)). BTTs were used early (in pts with no prior SSEs) for 51%, 32%, and 13% pts at CHUM, PMCC, and VGH respectively. ZA dosing frequency differed substantially between UOCs (Table 1).

Conclusions:

MBD-related HRU costs for Cdn pts with CRPC are high. Patterns of SSEs and BTT use varied between three Cdn UOCs.

Table 1.

POD-01.03. Frequency of ZA administration

	Overall	CHUM	PMCC	VGH
Patients receiving ZA	190	77	87	26
Patients receiving ZA q3w/q4w/qm, n (%)	78 (41%)	59 (77%)	9 (10%)	10 (38%)
Patients receiving ZA ≥q3m, n (%)	65 (34%)	3 (4%)	61 (70%)	1 (4%)
Patients receiving ZA at unknown frequency, n (%)	47 (25%)	15 (19%)	17 (20%)	15 (58%)

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S4.

POD-01.04: Prospective comparison of open vs. robot-assisted radical prostatectomy for clinically localized prostate cancer: Results from the University of Alberta radical prostatectomy database

Adrian S Fairey ¹, Niels-Erik Jacobsen ¹, Sunita Ghosh ², Derek Bochinski ¹, Michael Chetner ¹, Lucas Dean ¹, Howard Evans ¹, Michael Hobart ¹, David Mador ¹, Blair St Martin ¹, Keith F Rourke ¹, Eric Estey ¹

Abstract

Introduction and Objectives:

There are limited prospective data comparing outcomes of open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP) for clinically localized prostate cancer (CLPC). We compared ORP and RARP with respect to surrogate cancer control, functional preservation, perioperative, and healthcare utilization outcomes in men treated at the University of Alberta.

Methods:

A prospective analysis of data from the University of Alberta Radical Prostatectomy Database was performed. Between September 2007 and January 2013, 1806 consecutive men underwent radical prostatectomy for CLPC. The surgeon selected the surgical approach. Surrogate cancer control outcomes were biochemical recurrence (BCR; prostate-specfic antigen (PSA) ≥0.2 ug/L followed by a subsequent confirmatory value or initiation of salvage therapy) and positive surgical margin (R1) rate. Functional preservation outcomes were one-year urinary and erectile function preservation rates. Perioperative outcomes were 90-day complication and blood transfusion rates. Healthcare utilization outcomes were 90-day return to emergency room and/or readmission to hospital rates. The Kaplan-Meier method and multivariable Cox regression analyses were used to analyze BCR. Statistical tests were two-sided (p<0.05).

Results:

Complete data were evaluable for 1769 out of 1806 patients. 333 patients underwent ORP and 1436 patients underwent RARP. The median followup duration was 48 months. Baseline age (62 years vs. 61 years; p=0.07) and D’Amico risk stratification score (low-risk: 50% vs. 45%; intermediate-risk: 42% vs. 46%; high-risk: 8% vs. 9%; p=0.15) did not differ in the ORP and RARP groups. The five-year freedom from BCR rate differed between the ORP and RARP groups (79% vs. 86%; log rank p=0.006). Multivariable Cox regression analysis showed that ORP was independently associated with an increased risk of BCR (HR 1.62, 95% CI 1.21–2.18; p=0.001). The one-year urinary function preservation rate (60% vs. 72%; p=0.004), one-year erectile function preservation rate (10% vs. 17%; p=0.007), and blood transfusion rate (4% vs. 1%; p<0.001) differed between the ORP and RARP groups. There were no significant differences between groups for R1 rate (24% vs. 26%; p=0.57), 90-day complication rate (27% vs. 27%; p=0.27), return to emergency room rate (21% vs. 20%; p=0.54), or readmission to hospital rate (3% vs. 4%; p=0.15).

Conclusions:

In men treated at a Canadian academic centre, RARP provided superior cancer control, functional preservation, and blood product transfusion rates compared to ORP. Further analyses designed to examine mechanisms of differences in outcomes is underway.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S5.

POD-01.05: Cardiovascular and skeletal-related complications among patients treated with surgery or radiotherapy for clinically localized prostate cancer: A population-based cohort study

Christopher JD Wallis ^1,², Alyson L Mahar ¹, Raj Satkunasivam ¹, Sender Herschorn ¹, Ronald T Kodama ¹, Yuna Lee ³, Richard Choo ⁴, Cyril Danjoux ⁵, Steven A Narod ⁶, Robert K Nam ^1,²

Abstract

Introduction and Objectives:

Complications, including cardiovascular disease and skeletal-related events (SREs), from androgen-deprivation therapy (ADT) in the treatment of prostate cancer are well-described, but the role of primary therapy and its interaction with ADT is unknown among patients treated for clinically localized prostate cancer. We examined long-term rates of cardiovascular and SREs for these patients.

Methods:

We conducted a population-based, retrospective cohort study using the Surveillance, Epidemiology and End-Results (SEER) Medicare-linked databases for men aged 65–79 years who underwent radical prostatectomy or radiotherapy between 2001 and 2008 for cT1/T2 prostate cancer. We categorized treatment exposure according to primary treatment and receipt of ADT. We measured the cumulative incidence of cardiovascular and skeletal-related complications.

Results:

Among 60 156 men, 14 403 underwent primary surgery and 45 753 underwent radiotherapy. A higher proportion of patients treated with radiotherapy received ADT (52%) than did those treated with surgery (12%; p<0.0001). After a median followup of 6.0 years, patients treated with radiotherapy had an increased risk of coronary heart disease, myocardial infarction, sudden cardiac death, fracture, and fracture requiring hospitalization (adjusted hazard ratios 1.16–1.28; p<0.0001–0.04) compared to those treated with surgery. Patients receiving ADT had an increased risk of coronary heart disease, sudden cardiac death, fractures, and fractures requiring hospitalization (adjusted hazard ratios 1.18–1.32; p<0.0001–0.008), but not myocardial infarction (adjusted hazard ratio 1.04; p=0.5). We did not find evidence of significant interaction between local and systemic treatments.

Conclusions:

Cardiovascular disease and SREs are important complications for the treatment of clinically localized prostate cancer. The risk is higher among those treated with radiation or ADT and should be considered when discussing the risks and benefits of treatment for localized prostate cancer.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S5.

POD-01.06: Expressed prostatic secretion (EPS) biomarkers for the pre-surgical prediction of early biochemical recurrence

Jennifer Linehan ¹, Timothy G Wilson ¹, Mark Kawachi ¹, Clayton S Lau ¹, Rosa Meija ¹, Katarzya Lamparska ¹, Kristina Wittig ¹, Camille Amparo ¹, Daniel R Jeske ², Fang Lai ³, Steven S Smith ¹

Abstract

Introduction and Objectives:

Biochemical recurrence within 2.5–3 years after surgery is associated with higher risk of prostate-specific death. Consequently, predicting the likelihood that biochemical recurrence would not occur within 2.5 years would indicate a favorable surgical outcome. Our objective was to develop biomarkers in non-invasive specimens that would improve the prediction of early biochemical recurrence (BCR), defined as prostate-specific antigen (PSA) greather than 0.2 ng/ml detected within 2.5 years of surgery.

Methods:

Prospectively collected 855 expressed prostatic secretion (EPS) specimens prior to robot-assisted radical prostatectomy. 378 specimens have now been followed for biochemical recurrence over 2.5 years. We used quantitative reverse transcriptase polymerase chain reaction to quantify RNA expression from PSA, Thioredoxin Reductases 1 and 2, PCA3, and TMPRSS2:ERG fusions, along with a novel assay for the determination of PSA proteolytic activity (PPA). The data was modeled using logistic regression, random forests and cross-validated.

Results:

A baseline model using biopsy Gleason sum and serum PSA value was constructed with logistic regression. receiver operating curve (ROC) analysis gave an area under the curve (AUC) value for the absence of biochemical recurrence within 2.5 years of 0.8176. A model containing the PCA3 RNA level normalized to the input RNA value, and PPA, improve the AUC of the model to 0.8820. The difference in the values is statistically significant, with a p value of 0.0046. Random forest analysis was also applied to the data using all variables available, however, a statistical comparison showed that the logistic regression classifier was preferred. At 5% fixed false negative rate, adding PPA and PCA3 lab values to Gleason sum and serum PSA improved the false positive rate by 33%.

Conclusions:

PPA and PCA3 RNA are effective biomarkers in EPS specimens for the pre-surgical prediction of early biochemical recurrence after surgery, which should have use in counselling patients prior to prostatectomy.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S6.

POD-02.01: Conditional relapse-free survival in active surveillance for clinical stage I germ cell tumours

Madhur Nayan ¹, Michael A Jewett ¹, Ali Hosni ², Lynn Anson-Cartwright ¹, Philippe L Bedard ³, Peter Chung ², Padraig Warde ², Joan Sweet ⁴, Martin O’Malley ⁵, Eshetu G Atenafu ⁶, Robert J Hamilton ¹

Abstract

Introduction and Objectives:

While patients are counselled regarding their baseline risk of relapse on active surveillance (AS) for clinical stage I germ cell tumours (CSI GCTs), it would be beneficial to update their relapse risk estimate once patients have survived a period of time without relapse — a concept known as conditional survival. This has not been determined for CSI GCTs.

Methods:

We performed a retrospective review of 1239 patients with CSI GCTs managed with AS. Conditional relapse-free survival (cRFS) estimates were calculated by using the multiplicative law of probability at time periods coinciding with our AS followup protocol. We stratified patients according to validated risk factors for relapse. We used linear regression to determine cRFS trends over time. Models were validated using discrimination and calibration.

Results:

Disease relapse occurred in 126 (27%) of the 464 patients with CSI non-seminoma GCT (NSGCT). During the first five years, cRFS estimates increased from 58% to 100% in NSGCT patients with CSIB disease and pure embryonal carcinoma in orchiectomy pathology. Disease relapse occurred in 135 (17%) of the 775 patients with CSI seminoma. During the first five years, cRFS estimates increased from 80% to 97% for seminoma patients with tumour size ≥3cm. Over time, cRFS increased significantly (p<0.02) in all models stratified by risk factors for relapse in both NSGCT and seminoma. All models demonstrated good discrimination and calibration.

Conclusions:

cRFS increases rapidly over time in patients managed with AS for CSI seminoma and NSGCT. This information, when provided to patients, may aid in patient counselling and decrease anxiety; moreover, it could be used to adjust followup schedules to minimize radiation exposure and cost of surveillance.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S6–S7.

POD-02.02: Benchmarking quality for renal cancer surgery: Canadian Kidney Cancer information system (CKCis) perspective

Keith Lawson ¹, Olli Saarela ², Zhihui Liu ², Luke T Lavallee ³, Rodney H Breau ³, Lori A Wood ⁴, Michael A Jewett ¹, Anil Kapoor ⁵, Simon Tanguay ⁶, Ronald B Moore ⁷, Ricardo A Rendon ⁸, Frédéric Pouliot ⁹, Peter C Black ¹⁰, Jun Kawakami ¹¹, Darrel E Drachenberg ¹², Antonio Finelli ¹

Abstract

Introduction and Objectives:

There is a lack of validated quality metrics to evaluate the care of patients receiving renal cancer surgery. To address this knowledge gap, the Kidney Cancer Research Network of Canada defined a list of quality indicators (QI) to assess hospital-level performance. We have risk-adjusted these QIs to benchmark renal cancer surgical care at Canadian academic centres.

Methods:

A cohort study was performed using CKCis, which collects data from 15 Canadian hospitals. Hospital-level performance was measured by five QIs: overall partial nephrectomy rate (PNR), laparoscopic approach rate (LAR), PNR in patients with chronic kidney disease (CKDPNR), positive margin rate (PMR), PN complication rate (PNCx). To benchmark performance, the expected rate for a defined QI for each hospital was determined through multivariate regression modeling of patient-, tumour-, and treatment-related variables. Model accuracy was assessed by receiver operating curve (ROC) analysis to generate area under the curve (AUC) values. Observed-to-expected ratios (O/E ratio) with 95% confidence intervals (CI) were calculated for each QI on a hospital level. Hospitals where the O/E ratio CI do not overlap 1.0 were identified as displaying significant variations in quality for a given QI.

Results:

For PNR, LAR, CKDPNR, PMR, and PNCx, the risk model AUC values were 0.8, 0.8, 0.7, 0.6, and 0.6, respectively. Those models with AUC >0.7 were studied further. Of the CKCis hospitals, three (20%), three (20%), and two (13%) performed lower than expected for PNR, LAR, and CKDPNR, respectively. Hospital identity was an independent predictor of quality of care for PNR, LAR, and CKDPNR (p<0.001).

Conclusions:

Hospitals in CKCis display variation in performance for several renal cancer QIs with a minority performing worse than expected. Greater CKCis capture rates are required to improve the validity of these results and extend the utility of this database to real-world QI initiatives.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S7–S8.

POD-02.03: Survival outcomes of trimodal therapy compared with radical cystectomy for muscle-invasive bladder cancer: A propensity score-matched analysis of survival outcomes

Girish S Kulkarni ¹, Thomas Hermanns ², Kathy Li ¹, Yanliang Wei ¹, Bimal Bhindi ¹, Cynthia Kuk ¹, Srikala Sridhar ³, Theodorus van der Kwast ⁵, Peter Chung ⁴, Robert G Bristow ⁴, Padraig Warde ⁴, Michael Milosevic ⁴, Neil E Fleshner ¹, Michael A Jewett ¹, Alexandre Zlotta ¹

Abstract

Introduction and Objectives:

In our multidisciplinary bladder cancer clinic (MDBCC), patients have the opportunity to discuss various treatment options, including radical cystectomy (RC) or bladder-sparing trimodal therapy (TMT: endoscopic resection, radiotherapy, and chemotherapy). Although reports have shown comparable outcomes of TMT to cystectomy, no direct comparison to RC has been published and no randomized studies are available. We report our long-term outcomes of multidisciplinary care, comparing TMT to surgery using propensity-matched analyses.

Methods:

Patients seen in our MDBCC receiving TMT for muscle-invasive bladder cancer (MIBC) from 2008 to 2012 were identified and matched, using propensity scores, to patients operated by RC. Matching occurred on age, ECOG status, Charlson comorbidity score, cT stage, cN stage, and date of treatment. Overall survival (OS) and disease-specific survival (DSS) were assessed with Cox proportional hazards modeling and competing risk analysis, respectively.

Results:

Between 2008 and 2012, 248 patients were assessed in the MDBCC. Of these, 162 (65%) had MIBC. Nearly half (80) opted for radiotherapy +/− concurrent cisplatin chemotherapy and 49 underwent full bladder preservation with TMT as their primary therapy. We matched 48 TMT patients with 48 RC patients with no imbalances. Median age of the cohort was 67.5 years with 29.2% cT3/cT4. With a median followup time of 3.62 years, there were 19 (39.6%) deaths (seven from bladder cancer) in the RC group and 15 (31.3%) deaths (six from bladder cancer) in the TMT group. Five-year DSS was 85.2% and 84.7% with TMT and surgery, respectively (p>0.05). There was no statistically significant difference in DSS between the two groups (HR for TMT 1.31 (0.40–4.23; p=0.66) or in OS (HR for TMT 0.77 (0.34–1.75); p=0.53).

Conclusions:

In selected patients with MIBC, chemo-radiation yields survival outcomes similar to matched RC patients. BC patients should be offered the possibility to discuss various treatment options.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S9.

POD-02.04: Are renal tumour scoring systems better than clinical judgment at predicting partial nephrectomy complexity?

Ravi Kumar ¹, Luke T Lavallee ^1,², Darren Desantis ¹, Sonya Cnossen ², Ranjeeta Mallick ², Ilias Cagiannos ¹, Christopher G Morash ¹, Rodney H Breau ^1,²

Abstract

Introduction and Objectives:

Scoring systems, such as RENAL, PADUA, and centrality-index, objectively quantify the complexity of a renal tumour. Despite the validation of these scoring systems, they are infrequently used in clinical practice. The objective of this study was to determine how renal tumour scoring systems compare to clinical judgement in predicting time required for tumour removal and kidney reconstruction during partial nephrectomy.

Methods:

A consecutive cohort of partial nephrectomy patients treated at The Ottawa Hospital was included. Preoperative axial images were reviewed by four urologic oncologists who independently rated the complexity of a partial nephrectomy from 1–10 to generate a clinical judgment score. Two independent reviewers determined the RENAL, PADUA, and centrality-index scores. The time to complete tumour resection and renal reconstruction during partial nephrectomy was prospectively recorded. If renal hypothermia was used, the time to cool the kidney was not included.

Results:

During the study period, 116 partial nephrectomies were performed. The mean partial nephrectomy complexity score based on clinical judgment was 3.4 (SD 2.1) out of 10. There was good agreement between surgeons in assessing tumour complexity (intraclass correlation coefficient 0.72; 95% CI 0.65, 0.78). The mean RENAL score was 6.7 (SD 1.6) out of a maximum of 12, the mean PADUA score was 8.5 (SD 1.5) out of a maximum of 14, and the mean centrality index score was 3.8 (SD 2). Mean resection and reconstruction time was 24 minutes (SD 10 minutes). The correlation between clinical judgment score and time was 0.27 (p=0.005). The correlation between renal tumour scoring systems and time was 0.20 (p=0.04) for RENAL, 0.21 (p=0.03) for centrality-index, and 0.26 (p=0.007) for PADUA.

Conclusions:

Renal tumour scoring systems are not better than clinical judgment in predicting time required for tumour resection and renal reconstruction during partial nephrectomy.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S9.

POD-02.05: 2016 Prize Essay Competition Winner: Basic Science Effect of contrast media on urinary cytopathology specimens

Sebastian Frees ¹, Samir Bidnur ¹, Michael Metcalfe ¹, Peter Raven ¹, Claudia Chavez-Munoz ¹, Igor Moskalev ¹, Ladan Fazli ¹, Alan I So ¹

Abstract

Introduction and Objectives:

Urological dogma dictates that washings collected from the urinary tract for cytological assessment must be performed without interference from contrast agents that may alter cellular integrity and diagnostic interpretation. In practice, the initial contrast used to outline the upper tracts is commonly discarded with subsequent saline washings sent for cytology. We hypothesize that contrast washings do not affect the morphology of urothelial carcinoma cells or the integrity of cytology interpretation.

Methods:

Urine obtained from 1) a human xenograft bladder cancer model using UC-3 cells; 2) patients with urothelial carcinoma; and 3) patients without urothelial cancer were subjected to various experimental solutions (water, saline, urine, and dilutions of contrast media) for different exposure times. After exposure to various different solutions, cells underwent cytological analysis to assess morphologic and degenerative changes.

Results:

No cytological differences were seen when cells were exposed to ionic, hyperosmolar, and non-ionic low-osmolar contrast agents for any exposures up to five minutes. Cells exposed to mixtures of contrast agents and urine also demonstrated no evidence of degenerative change. Cells exposed to water for greater than one minute demonstrated significant hydropic degeneration impacting cytological interpretation. At 40 minutes or later, all reagents except urine caused severe degeneration. These results were confirmed when using urine from the mouse bladder cancer model and from human urine.

Conclusions:

Commonly used contrast agents have no effect on urinary cytology up to five minutes. Contrast washings of the urinary tract should not be discarded and can be sent for cytological diagnosis if fixed within this time period

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S9.

POD-02.06: Overall prevalence of malignancy and the differential diagnosis of Bosniak III renal lesions based on lesion size

Cameron Lam ¹, Anil Kapoor ²

Abstract

Introduction and Objectives:

The aim of this study was to evaluate the pathological results of renal masses in comparison with Bosniak III renal cystic lesions to determine the actual malignancy risk.

Methods:

A retrospective review of all Bosniak III renal lesions identified by computed tomography (CT) or magnetic resonance imaging (MRI) in our department were collected from all adult (>18 years of age) patients from August 1, 2013 to December 31, 2015 who underwent surgical excision. Surgical pathology, including TMN stage, histology, and Fuhrman grade, was collected, along with maximum lesion size. 25 patients were identified for this study and a two-tailed two-sample t-test was used to compare lesion size between malignant and benign lesions.

Results:

Of the 25 cases, 15/25 (60%) of Bosniak III lesions were determined to be malignant. All malignant lesions were classified as less aggressive malignancies as either Fuhrman Grade 1 or 2 with no evidence of progression to Bosniak IV. On average, a larger lesion size trended towards pathological identification of benign complex cysts in comparison to a RCC (5.66 ± 2.53 cm vs. 4.09 ± 2.91 cm).

Conclusions:

The malignancy risk of Bosniak III renal lesions is 60% in our study. Surgical excision should remain the recommended management option for patients who are good surgical candidates. Our study also identified that all identified Bosniak III lesions were of low Fuhrman grade, with no evidence of progression, which suggests a better prognosis. No patient in this study developed metastatic disease within the three year followup period. Finally, lesion size data suggest that the larger the complex Boxniak III cyst, the more likely to be benign.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S10.

POD-03.01: Efficacy and safety of a novel, oral SH2-containing inositol-5′-phosphatase 1 activator, AQX-1125, in subjects with moderate to severe interstitial cystitis/bladder pain syndrome

J Curtis Nickel ¹, Blair Egerdie ², Edward Davis ³, Robert Evans ⁴, Heidi Biagi ⁵, Stephen Shrewsbury ⁵

Abstract

Introduction and Objectives:

AQX-1125, a novel SH2-containing inositol-5′-phosphatase 1 (SHIP1) activator previously demonstrated to modulate inflammation. We conducted a double-blind, placebo-controlled phase 2 trial of the safety and efficacy of AQX-1125 (plus existing therapy) for the treatment of interstitial cystitis/bladder pain syndrome (IC/BPS).

Methods:

69 women with moderate to severe IC/BPS were randomized to daily 200 mg AQX-1125 or placebo for six weeks. Daily average and maximal pain scores were recorded and urinary frequency prior to visits. The O’Leary-Sant Interstitial Cystitis Symptom and Problem Indexes (ICSI/PI), Bladder Pain IC Symptom Score (BPIC-SS) and Short-Form 12v2 questionnaires were administered. Safety data was collected through treatment and four weeks followup.

Results:

At six weeks, average daily e-diary pain (primary efficacy outcome), clinic average pain, maximum pain (e-diary and clinic), and percent change in average pain decreased more with AQX-1125. Significant benefits were noted for the ICSI/PI and BPIC-SS. No safety issues were noted in either group.

Conclusions:

AQX-1125 provided greater reduction in bladder pain and symptoms at six weeks, compared to placebo in women with moderate to severe IC/BPS and was well-tolerated. This data supports the development of AQX-1125 as a novel, once-daily oral therapy for IC/BPS.

Table 1.

POD-03.01. Efficacy results (change from baseline to 6 weeks)

	Placebo (N=32)	AQX-1125 (N=37)
	Mean (SE)		LS mean difference	p value
Average pain (e-diary)	−1.4 (0.3)	−2.4 (0.4)	1.0 (0.5)	0.061
Average pain (clinic)	−1.1 (0.4)	−2.6 (0.5)	1.6 (0.6)	0.008
Percent change from baseline	−21.1 (4.8)	−38.1 (5.8)	16.5 (7.8)	0.039
Maximum pain (e-diary)	−1.4 (0.4)	−2.6 (0.4)	1.3 (0.6)	0.030
Maximum pain (clinic)	−1.1 (0.5)	−2.8 (0.6)	1.6 (0.7)	0.028
O’Leary-Sant ICSI	−1.4 (0.6)	−3.8 (0.6)	2.7 (0.9)	0.005
O’Leary-Sant ICPI	−1.6 (0.5)	−3.6 (0.7)	2.5 (1.0)	0.014
BPIC-SS	−4.0 (1.2)	−8.8 (1.4)	5.4 (2.1)	0.011

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Footnotes

Funded by Aquinox Pharmaceuticals Inc.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S10–S11.

POD-03.02: Mirabegron add-on treatment to solifenacin in incontinent overactive bladder patients: A responder analysis of a randomized, double blind, phase 3b study

Scott MacDiarmid ¹, Salman Al-Shukri ², Jack Barkin ³, Aino Fianu-Jonasson ⁴, Philippe Grise ⁵, Sender Herschorn ⁶, Moses Huang ⁷, Emad Siddiqui ⁷, Matthias Stölzel ⁸, Claire Hemsted ⁷, Marcus J Drake ⁹

Abstract

Introduction and Objectives:

Incontinence is detrimental to health-related quality of life (HRQoL). This study (NCT01908829) assessed responder rates for efficacy and patient-reported outcomes (PROs) after treatment with a combination (COMBN) of a β3-adrenoceptor agonist, mirabegron (MIRA) and an antimuscarinic, solifenacin (SOLI), in incontinent overactive bladder (OAB) patients with inadequate response to SOLI 5 mg.

Methods:

Incontinent adults with OAB for ≥3 months received a two-week wash-out and four weeks single-blind daily SOLI 5 mg. Patients still reporting ≥1 incontinence episodes during a three-day diary were randomized (1:1:1) to daily double-blind treatment with COMBN (SOLI 5 mg + MIRA 25 mg, increasing to MIRA 50 mg at four wks), SOLI 5 mg or 10 mg for 12 weeks. At end of treatment, responder rates for incontinence (zero episodes post-Baseline [‘dry rate’], ≥50% decrease in episodes/24 hours); micturition reduction to <8 micturitions/24hours; and PROs (exceeding minimally important differences (MID) threshold in patient perception of bladder condition (PPBC) and OAB-questionnaire (OAB-q) Symptom Bother/total HRQoL scores) were evaluated individually or as double/triple responder analyses (50% reduction in incontinence plus OAB-q and/or PPBC).

Results:

Baseline characteristics were similar between groups (COMBN, n=707; SOLI 5 mg, n=705; SOLI 10 mg, n=698). Odds for achieving full continence were 47% and 28% higher for COMBN vs. SOLI 5 mg or 10 mg, respectively; improvements in OAB-q outcomes were statistically significant. Responder rates for ≥50% decreased incontinence, micturition reduction, and PPBC were also improved for COMBN vs.SOLI 5 mg. Significant improvements in favour of COMBN vs. SOLI 5 mg were found for all double/triple responder analyses (p<0.001) and three variables for COMBN vs. SOLI 10 mg (p<0.05).

Conclusions:

Mirabegron add-on treatment to solifenacin significantly improved responder rates, notably ‘dry rate,’ and PROs, and may be beneficial for incontinent OAB patients with an inadequate response to solifenacin.

Table 1.

POD-03.02. Proportion of responders at end of treatment (EoT) and odds ratios for COMBN vs SOLI 5 mg and 10 mg

	COMBN	SOLI 5 mg	SOLI 10 mg
Zero incontinence episodes/24 h at EoT (‘dry rate’)

Responders, n (%)	325 (46.0) [n=706]	267 (37.9) [n=704]	280 (40.2) [n=697]
Odds ratio COMBN vs SOLI 5 mg (95% CI)	1.47 (1.17, 1.84) p=0.001
Odds ratio COMBN vs SOLI 10 mg (95% CI)	1.28 (1.02, 1.61) p=0.033

50% decrease in mean number of incontinence episodes/24 h

Responders, n (%)	503 (71.2) [n=706]	444 (63.1) [n=704]	464 (66.6) [n=697]
Odds ratio COMBN vs SOLI 5 mg (95% CI)	1.51 (1.20, 1.90) p<0.001
Odds ratio COMBN vs SOLI 10 mg (95% CI)	1.25 (0.99, 1.57) p=0.063 NS

Mean of ≥8 micturitions at baseline and average of <8 micturitions/24 h at EoT

Responders, n (%)	213 (30.2) [n=706]	176 (25.0) [n=704]	193 (27.7) [n=697]
Odds ratio COMBN vs SOLI 5 mg (95% CI)	1.29 (1.02, 1.64) p=0.036
Odds ratio COMBN vs SOLI 10 mg (95% CI)	1.12 (0.89, 1.42) p=0.334 NS

MID (≥10-point improvement from baseline) in OAB-q symptom bother

Responders, n (%)	567 (81.7) [n=694]	490 (71.7) [n=683]	504 (74.6) [n=676]
Odds ratio COMBN vs SOLI 5 mg (95% CI)	1.75 (1.34, 2.30) p<0.001
Odds ratio COMBN vs SOLI 10 mg (95% CI)	1.54 (1.17, 2.02) p=0.002

MID (≥10-point improvement from baseline) in OAB-q total HRQoL

Responders, n (%)	476 (68.6) [n=694]	414 (60.6) [n=683]	406 (60.1) [n=676]
Odds ratio COMBN vs SOLI 5 mg (95% CI)	1.50 (1.17, 1.91) p=0.001
Odds ratio COMBN vs SOLI 10 mg (95% CI)	1.47 (1.15, 1.89) p=0.002

MID (≥1-point improvement from baseline) in PPBC

Responders, n (%)	533 (76.5) [n=697]	478 (69.5) [n=688]	491 (71.9) [n=683]
Odds ratio COMBN vs SOLI 5 mg (95% CI)	1.43 (1.11, 1.84) p=0.006
Odds ratio COMBN vs SOLI 10 mg (95% CI)	1.26 (0.97, 1.63) p=0.081 NS

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Odds ratios, two-sided 95% CIs for odds ratios, and p-values are from a logistic regression model including treatment group, sex, age group (<65, ≥65 y), 4-wk incontinence episode reduction group (after 4 wks of SOLI 5mg in the single-blind treatment period, patients were classified into groups based on the level of reduction in incontinence episodes - <50% or ≥50%), geographic region as factors and baseline value as covariate. p<0.05 indicates superiority in favour of COMBN treatment vs SOLI monotherapy. NS: non-significant.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S11.

POD-03.03: A randomized controlled trial examining dose response of cranberry in the treatment of lower urinary tract infections in women and human urine cranberry metabolites

Lynn Stothers ¹, Paula Brown ², Marc Levine ³, Howard Fenster ¹, Jonathan Berkowitz ⁴

Abstract

Introduction and Objectives:

Studies examining the use of cranberry to prevent urinary tract infection (UTI) in human subjects have demonstrated variable effectiveness with varying exposure. This sudy aimed to establish if UTI has a dose response to oral cranberry juice and to demonstrate cranberry metabolites in human urine via quantification of peonidin-3-O-galactoside (P3Ga) post-consumption.

Methods:

This was a randomized, controlled trial of placebo vs. low- and medium-dose exposure to twice daily oral cranberry juice intake for one year. Human urine was collected prior to and during exposure. Physicians, nursing staff, urine chemistry team and statistician were blinded to treatment assignment. Primary outcome was the number of symptomatic UTIs (culture positive, single organism, acute symptoms).

Results:

263 women (19–85 years) participated. When treated as a categorical variable, using all 263 cases (intent to treat) there was no statistical difference in the number of UTIs between groups. If only subjects completing six months or more are considered, there is a weakly statistically significant difference between placebo (43% one or greater UTIs compared with 25% and 28% in low and moderate groups). If treated as a continuous variable using all 263 cases (intent to treat), statistics support weak evidence of a difference in mean UTIs. If restricted to those completing six months or more, there is strong evidence of a difference in the three groups (p=0.029). Kruskal-Wallis test confirms these findings. Increasing amounts of P3Ga are detectable in human urine, confirming cranberry anthocyanins post-ingestion.

Conclusions:

Intent-to-treat analysis supports weak evidence or no difference between placebo and cranberry depending on treatment as a continuous or categorical variable. Subjects continuing for six months to one year demonstrated a statistical difference between placebo and cranberry, with no difference low and medium doses. Increasing amounts of P3Ga are detectable in human urine with twice daily cranberry intake.

Acknowledgments

NIH NCCAM.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S12.

POD-03.04: The efficacy and safety of onabotulinumtoxinA or solifenacin compared to placebo in solifenacin-naïve patients with overactive bladder: Results from a multicentre, randomized, double-blind trial

Sender Herschorn ¹, Philip Aliotta ², Kurt McCammon ³, Karel Everaert ⁴, Rajagopalan Sriram ⁵, Steve Abrams ⁶, Wayne Lam ⁶, Alfred Kohan ⁷

Abstract

Introduction and Objectives:

We compared the efficacy and safety of onabotulinumtoxinA (onabotA) 100 U or solifenacin (soli) with placebo (pbo) in soli-naïve patients with overactive bladder (OAB) who were inadequately managed by anticholinergic medications. A post-hoc analysis compared onabotA and soli.

Methods:

This double-dummy, double-blind study randomized patients 2:2:1 to onabotA 100 U/oral pbo (n=145), soli 5–10 mg/pbo injection (n=151), or double pbo (n=60). Assessments (Week 12) included least-squares (LS) mean change from baseline (BL) in urinary incontinence (UI; co-primary), micturition and nocturia episodes/day, mean percent reduction in UI, proportion of patients with 100% (co-primary) and ≥50% UI reduction, treatment-emergent adverse events (TEAEs), and initiation of clean intermittent catheterization (CIC).

Results:

356 patients were randomized; discontinuations due to AEs and lack of efficacy were 3.1% and 0.3%, respectively. For the onabotA, soli, and pbo groups, mean UI reductions/day were −3.2^*, −2.6^*, and −1.3, respectively; proportion of patients achieving 100% UI reduction were 33.8%^*, 24.5%^*, and 11.7%, respectively; and proportions of patients achieving ≥50% UI reduction were 77.2%^*, 64.9%^*, and 33.3%, respectively. Mean reductions in micturition episodes were −2.3^*, −2.1^*, and −1.16 for the onabotA, soli, and pbo groups, respectively, and reductions in nocturia episodes were −0.6, −0.5, and −0.3, respectively. In the post-hoc analysis, mean UIE reductions/day were significantly greater with onabotA versus soli (p=0.022). Higher proportions of onabotA-treated patients achieved 100% (p=0.107) and ≥50% (p=0.025) UIE reduction versus soli. Most common TEAEs were UTI, bacteriuria, and dry mouth. CIC rates were 6.2% (onabotA), 0.7% (soli), and 0.0% (pbo).

Conclusions:

OnabotA resulted in greater reductions in daily UIE and higher proportions of patients with 100% and ≥50% UIE reductions than soli or pbo, with 1/3 of patients becoming ‘dry.’ No new safety signals were observed.

Footnotes

^*

p <0.05 vs. pbo.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S12–S13.

POD-03.05: Cardiovascular assessments in a randomized, double-blind, phase 3b trial of mirabegron add-on treatment in incontinent overactive bladder patients

Marcus J Drake ¹, Christopher R Chapple ², Ahmed A Esen ³, Stavros Athanasiou ⁴, Javier Cambronero ⁵, David Mitcheson ⁶, Sender Herschorn ⁷, Moses Huang ⁸, Emad Siddiqui ⁸, Matthias Stölzel ⁹, Claire Herholdt ⁸, Scott MacDiarmid ¹⁰

Abstract

Introduction and Objectives:

Mirabegron (MIRA) is a potent, selective β3-adrenoceptor agonist. Cross-reactivity with β1-adrenoceptors in the cardiovascular (CV) system is low. This study (NCT01908829) assessed efficacy endpoints, vital signs, and electrocardiogram (ECG) changes after treatment with a combination (COMBN) of MIRA and an antimuscarinic solifenacin (SOLI), in incontinent overactive bladder (OAB) patients with inadequate response to SOLI 5 mg.

Methods:

Incontinent adults with OAB for ≥3 months received a two-week wash-out and four weeks single-blind daily SOLI 5 mg. Patients still reporting ≥1 incontinence episode(s) during a three-day diary were randomized (1:1:1) to daily double-blind treatment with COMBN (SOLI 5mg + MIRA 25 mg, increasing to MIRA 50 mg after four weeks), SOLI 5 mg, or SOLI 10 mg for 12 weeks. Vital signs assessed in the clinic included changes from baseline (BL) to end of treatment (EoT) in pulse rate (PR) and systolic/diastolic blood pressure (SBP/DBP). BL to EoT changes in Fridericia’s corrected QT interval (QTcF) were determined from 12-lead ECG.

Results:

All treatment groups had similar baseline characteristics (COMBN, n=725; SOLI 5 mg, n=728; SOLI 10 mg, n=719). The 1 mmHg SBP difference for COMBN vs. SOLI 10 mg resulted from decreased SBP with SOLI rather than increased SBP with COMBN. Percentage of patients with increased PR, SBP, or DBP at EoT meeting change from BL criteria was similar across groups, except a slight increase in those with ≥15 mmHg in DBP in both SOLI 5 mg and 10 mg vs. COMBN. Tachycardia incidence (PR ≥100 bpm during any assessment) was low (≤1.7%). Small dose-related BL to EoT increases in QTcF were observed for SOLI 10 mg, as in previous trials. QTcF changes were similar for COMBN and SOLI 5 mg. No clinically meaningful between-group differences were seen for BL to EoT changes for any vital sign. No additional effects were observed in ECG or QTcF findings for COMBN therapy.

Conclusions:

In OAB patients with refractory incontinence, mirabegron add-on treatment to solifenacin results in an acceptable CV profile.

Table 1.

POD-03.05. Change from Baseline to EoT in vital signs and QTcF for COMBN vs SOLI 5 mg and SOLI 10 mg monotherapy

	COMBN	SOLI 5 mg	SOLI 10 mg
Change from baseline to EoT in PR	(n=725)	(n=728)	(n=719)

Mean adjusted change in PR, bpm (SE) [95% CI]	0.47 (0.28) [−0.09, 1.02]	0.43 (0.28) [−0.12, 0.98]	0.27 (0.28) [−0.28, 0.83]
Mean treatment difference (COMBN vs monotherapy) (SE) [95% CI]		0.04 (0.40) [−0.75, 0.82]	0.19 (0.40) [−0.59, 0.98]
Patients w/change from baseline, n (%)^*	n=710	n=715	n=708
≥5 bpm increase	47 (6.6)	53 (7.4)	59 (8.3)
≥10 bpm increase	14 (2.0)	16 (2.2)	12 (1.7)
≥15 bpm increase	5 (0.7)	2 (0.3)	1 (0.1)

Change from baseline to EoT in SBP	(n=725)	(n=728)	(n=719)

Mean adjusted change in SBP, mmHg (SE) [95% CI]	0.07 (0.38) [−0.68, 0.83]	−0.93 (0.38) [−1.68, −0.18]	−1.28 (0.38) [−2.03, −0.52]
Mean treatment difference (COMBN vs monotherapy) (SE) [95% CI]		1.01 (0.54) [−0.06, 2.07]	1.35 (0.54) [0.29, 2.42]
Patients w/change from baseline, n (%)^*	n=710	n=715	n=709
≥10 mm Hg increase	24 (3.4)	31 (4.3)	26 (3.7)
≥15 mm Hg increase	13 (1.8)	13 (1.8)	9 (1.3)
≥20 mm Hg increase	2 (0.3)	4 (0.6)	5 (0.7)

Change from baseline to EoT in DBP	(n=725)	(n=728)	(n=719)

Mean adjusted change in DBP, mmHg (SE) [95% CI]	−0.35 (0.26) [−0.86, 0.16]	−0.45 (0.26) [−0.96, 0.05]	−0.48 (0.26) [−0.99, 0.03]
Mean treatment difference (COMBN vs monotherapy) (SE) [95% CI]		0.10 (0.36) [−0.61, 0.82]	0.13 (0.37) [−0.59, 0.85]
Patients w/change from Baseline, n (%)^*	n=710	n=715	n=709
≥5 mm Hg increase	53 (7.5)	56 (7.8)	57 (8.0)
≥10 mm Hg increase	15 (2.1)	18 (2.5)	14 (2.0)
≥15 mm Hg increase	1 (0.1)	4 (0.6)	4 (0.6)

Change from baseline to EoT in QTcF	(n=725)	(n=728)	(n=719)

Mean change from baseline, msec, (SD)	0.49 (13.23)	0.77 (12.98)	3.30 (13.72)

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Vital signs were analyzed in the Safety Analysis Set (SAF; all randomized patients who received ≥1 dose of any double-blind treatment). Adjusted change from baseline values and 95% CIs were generated from an ANCOVA model with treatment group, sex, age group (<65, ≥65 years), 4-wk incontinence reduction group (at randomization following 4 wks SOLI 5 mg treatment), and geographic region as fixed factors and baseline as a covariate.

^*

Values are from SAF patients with 3 consecutive post-baseline values.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S12–S13.

POD-03.06: Impact of prostatectomy modality on successful management of urethral complications after radical prostatectomy

Joseph LaBossiere ¹, Nathan Hoy ¹, Keith F Rourke ¹

Abstract

Introduction and Objectives:

Although radical prostatectomy has been significantly refined by the use of robot-assisted surgery, urethral complications, such as vesicourethral stenosis (VUS) and incontinence, still occur. It is unclear if the type of prostatectomy influences successful management of post-prostatectomy complications. Our objective is to determine if prostatectomy modality impacts successful treatment of urethral complications after radical prostatectomy.

Methods:

Review of 292 patients over a 10-year period with VUS managed endoscopically, or patients with post-prostatectomy incontinence (PPI) treated with insertion of an artificial urinary sphincter (AUS) or urethral sling were included in the study. Patients were divided into two groups: those undergoing open radical prostatectomy (ORP) and or robot-assisted prostatectomy (RALP). Patients were excluded if type of prostatectomy was not explicitly clear. Treatment success of VUS was defined as no evidence of recurrent stenosis <16 Fr on cystoscopy and resolution of incontinence (<1 pad/day) for patients with post-prostatectomy incontinence.

Results:

292 patients required 442 treatments for either VUS (292) or incontinence (68 AUS, 82 slings). 125 patients underwent ORP, while 167 underwent RALP. Groups did not differ with regard to age, stage, body mass index (BMI), radiation, and comorbidities. Treatment success of individual procedures was 57%, with a mean followup of 10 months. When stratified by prostatectomy modality, overall treatment success was significantly higher in patients with a history of RALP (62%) compared to ORP (52%; p=0.03). On subgroup analysis, there was no significant difference in AUS (p=0.34) and VUS (p=0.78) treatment success when stratifying for prostatectomy modality. However, patients treated with a urethral sling had significantly higher success in the RALP group (89.8%) compared to the ORP group (69.6%; p=0.02). On multivariate analysis prostatectomy modality remained significantly associated with treatment success (OR 4.2; 1.1–16.1; p=0.04), whereas age (p=0.57) and cancer stage (p=0.57) were not.

Conclusions:

Type of prostatectomy influences successful treatment of urethral complications post-prostatectomy. Specifically, patients undergoing laparoscopic prostatectomy may have better outcomes with male slings when compared to those who underwent open prostatectomy.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S14.

POD-04.01: A randomized, controlled trial of bladder training video vs. standard urotherapy for bladder and bowel dysfunction

Rahul K Bansal ¹, Mandy Rickard ¹, Natasha Brownrigg ¹, Kizanee Jegatheeswaran ¹, Christine Li ¹, Bethany Easterbrook ¹, Melissa McGrath ¹, Jorge E DeMaria ¹, Armando J Lorenzo ², Luis H Braga ¹

Abstract

Introduction and Objectives:

Controversy surrounds which treatment modality is most effective in reducing symptoms in children with bladder/bowel dysfunction (BBD). Herein, we examine if an animated bladder training video (BTV) is as effective as standard urotherapy (SU) in improving BBD symptoms.

Methods:

Non-inferiority, randomized, controlled trial including patients aged 5–10 years who scored ≥11 on the BBD symptomology Vancouver questionnaire. Children with vesicoureteral reflux, neurogenic bladder, learning disabilities, recent urotherapy, and primary nocturnal enuresis were excluded. BBD symptoms were evaluated at baseline and at three-month followup (F/U). A sample size of 126 ensured a non-inferiority margin of 3.5 difference in scores between groups. An intention-to-treat protocol was followed, and baseline vs. F/U scores were compared with paired parametric tests.

graphic file with name cuaj-5-6-s3f34.jpg

Results:

Of 539 screened patients, 173 (32%) were eligible and 150 (28%) enrolled. Of these, 122 (81%) completed the trial, 21 (14%) are active, five (3%) were lost to F/U, and two (1%) withdrew. Baseline characteristics were similar between groups with scores of 20.0 ± 6 and 19.8 ± 8(p=0.82) for BTV and SU respectively (Table 1). At F/U, both BTV and SU scores reduced to 14.1 ± 7 and 13.8 ± 6 (p=0.81), respectively. The mean change in symptomology scores in BTV and SU was 5.8 ± 5.8 and 6.2 ± 6.1, respectively, and the difference was −0.4 (97.5% CI: −2.5–1.7). The upper limit CI did not exceed the 3.5 non-inferiority margin.

Conclusions:

BTV is not inferior to SU in reducing BBD symptoms in children aged 5–10 years with BBD. BTV ensures patients are consistently provided the same information regardless of provider or setting. BTV appears to be an effective alternative to SU, as families can independently access and review BTV as often as necessary, thus maximizing the use of limited resources without adversely impacting outcomes.

Table 1.

POD-04.01.

Characteristic	BTV n=75 (%)	SU n=75 (%)	p value
Gender
Male	21 (28)	24 (32)	0.59
Female	54 (72)	51 (68)
Age (years)	7.0 ± 1.7	6.9 ± 1.6	0.62
Presenting symptoms
Daytime incontinence (daily)	17 (23)	16 (21)	0.84
Recurrent UTI (minimum 2)	36 (48)	35 (47)	0.87
Frequency (more than 8 voids daily)	16 (21)	18 (24)	0.70
Urgency (rush to pee every day)	29 (39)	21 (28)	0.17
Constipation (Bristol Stool Chart ≤3; bowel movements other than daily; hard stools)	58 (77)	58 (77)	1.00
Anticholinergic prescription	24 (32)	23 (31)	0.86
Mean change in symptomology score	5.8 ± 5.8	6.2 ± 6.1	0.71
Number of pts who had an increase in score	9 (12)	8 (11)	0.97
Mean followup time (months)	3.4 ± 1.0	3.7 ± 1.7	0.32

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S14.

POD-04.02: The incidence and predictors of peripheral nerve injury during abdominal-pelvic surgery: Results from the National Surgical Quality Improvement Program (NSQIP) Database

Christopher JD Wallis ¹, Sarah Peltz ¹, Jamie Kroft ², Robert K Nam ¹, Raj Satkunasivam ¹

Abstract

Introduction and Objectives:

Peripheral nerve injury (PNI) is a rare, but preventable complication of surgery. We sought to determine the rate of PNI following common abdominal and pelvic procedures and to determine the impact of minimally invasive surgical techniques on these rates.

Methods:

Using the American College of Surgeons National Surgical Quality Improvement database, we examined rates of PNI among patients undergoing appendectomy, hysterectomy, colectomy, or radical prostatectomy between January 1, 2005 and December 31, 2012. We examined trends in peripheral nerve injury over time and assessed the influence of minimally invasive surgical techniques, in addition to relevant clinical and demographic factors in multivariable logistic regression models.

Results:

Between 2005 and 2012, 297 532 patients underwent appendectomy, hysterectomy, colectomy or radical prostatectomy. The overall rate of PNI was 0.03%. 44 patients treated using minimally invasive surgical techniques had PNI (0.03%) as compared to 63 that underwent open surgery (0.05%; p=0.0002). During the study period, there was a statistically significant decrease in the proportion of surgeries resulting in PNI (p<0.0001). Increased operative time (odds ratio (OR) 1.09 per 10 min, 95% CI 1.06–1.11), smoking status (OR 1.60, 95% CI 1.04–2.46), and body mass index (BMI) (OR 1.57 for BMI >30 compared to 18.5–25, 95% CI 1.00–2.47) were associated with an increased risk of PNI. Use of minimally invasive surgical approach was not associated with the risk of PNI (OR 0.71, 95% CI 0.47–1.09).

Conclusions:

Prolonged operative time, smoking, and obesity are associated with an increased risk of postoperative PNI. Minimally invasive approaches to common abdominal-pelvic surgeries do not appear to increase the risk of PNI. Increasing awareness of this highly preventable complication may serve to further reduce incidence rates and improve patient care.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S15.

POD-04.03: Dusting vs. basketing during ureteroscopic lithotripsy: A multicentre prospective trial from the EDGE Research Consortium

Ben H Chew ¹, Ojas Shah ², Roger L Sur ³, Bodo E Knudsen ⁴, Brian R Matlaga ⁵, Amy E Krambeck ⁶, Nicole L Miller ⁷, Manoj Monga ⁸, Mitchell R Humphreys ⁹

Abstract

Introduction and Objectives:

There is little evidence as to whether dusting stones is more efficacious than basket extraction of fragments during ureteroscopic lithotripsy. We prospectively followed patients to determine which method resulted in the higher stone-free rate.

Methods:

Patients undergoing ureteroscopy for renal stones between 5–20 mm were eligible. The Endourology Disease Group for Excellence (EDGE) includes high-volume stone centres with well-established dusting (four sites) or basketing (four sites) approaches to renal calculi. Laser lithotripsy was used and patients were imaged within three months following ureteroscopy. The definition of stone-free was no fragments of any size on kidneys-ureters-bladder (KUB) and ultrasound imaging. All patients were stented postoperatively and given alpha blocker for 30 days.

Results:

59 patients were enrolled and followed for three months (n=36 basketing, n=23 dusting). The stones were slightly larger in the dusting group and significantly more laser energy was used in the dusting group. Operating room time was longer in the basketing group. There were fragments present in 4/36 (11.1%) in the basketing group compared to 9/23 (39.1%) of the dusting group. The stone-free rate was 89.1% in the basketing group and 60.9% in the dusting group. Only one patient from each group became symptomatic. There was no difference in emergency room admission or hospitalization between groups (18.4% dusting vs. 12% basketing) or in re-intervention rates (one dusting, two basketing).

Conclusions:

Our analysis shows that in patients undergoing ureteroscopy for renal stones between 5–20 mm that active extraction of all fragments with a basket produces a higher stone-free rate (89.9%) than dusting the stone (60.9%). However, there was no difference in readmission or reintervention rates and only one patient in each group became symptomatic from their residual fragments. Long-term followup of these patients will also determine the fate of these fragments and whether they become symptomatic and require treatment.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S15–S16.

POD-04.04: Is shockwave lithotripsy a risk factor for developing diabetes mellitus? A population-based cohort study

Michael Ordon ^1,², Jason Y Lee ¹, Daniela Ghiculete ¹, R John D Honey ¹, Kenneth T Pace ¹

Abstract

Introduction and Objective:

Our objective was to perform a population-based, retrospective cohort study to determine if patients treated with shockwave lithotripsy (SWL) are at a greater risk for the development of diabetes mellitus (DM) than those treated with ureteroscopy (URS).

Methods:

All SWL and URS treatments performed in Ontario between January 1994 and December 2012 were identified using linked administrative healthcare databases. The primary outcome was the development of DM >90 days following treatment. SWL, the study exposure, was used as a time-dependent exposure to account for those who underwent SWL following URS. Unadjusted analysis with the Kaplan-Meier method was used to examine the time to development of DM across both groups. Multivariable analysis with Cox proportional hazards regression was used to assess the risk for DM between SWL and URS groups while controlling for age, gender, region of residence, income quintile, and comorbidity index. A sensitivity analysis was performed adjusting the time frame window for development of DM to a minimum of >180 and 365 days following treatment, respectively.

Results:

We identified 99 144 patients who underwent SWL or URS, with a median followup of 6.6 years (SWL 8.5 years, URS 5.6 years). The groups had similar baseline characteristics. Unadjusted survival analysis demonstrated an increased risk for the development of DM in the SWL group compared to the URS group (p<0.0008). Similarly, multivariable analysis demonstrated an increased risk of DM in the SWL cohort (HR 1.08, 95% CI 1.04–1.12; p<0.0001). Sensitivity analysis revealed comparable results with an increased risk of DM in the SWL cohort both with the time for exclusion increased to 180 days (HR 1.08, 95% CI 1.04–1.12; p<0.0001) and 365 days (HR 1.09, 95% CI 1.05–1.13; p<0.0001).

Conclusions:

Our population-based cohort study demonstrated a small, but significant increased risk of DM in patients undergoing SWL compared to URS.

Table 1.

POD-04.04. Baseline characteristics for patients treated with SWL and URS from January 1, 1994 to December 31, 2012

Characteristic	SWL n=46 318	URS n=47 773	URS then SWL n=5053
Demographics
Age (years)
Median (IQR)	49 (39–59)	49 (38–61)	47 (37–58)
Sex, n (%)
Female	16 740 (36.1%)	18 391 (38.5%)	1937 (38.3%)
Male	29 578 (63.9%)	29 382 (61.5%)	3116 (61.7%)

Income quintile, n (%)
Missing	122 (0.3%)	119 (0.2%)	18 (0.4%)
1- Lowest	8585 (18.5%)	9195 (19.2%)	871 (17.2%)
2	8884 (19.2%)	9755 (20.4%)	1059 (21.0%)
3	9173 (19.8%)	9621 (20.1%)	1051 (20.8%)
4	9632 (20.8%)	9907 (20.7%)	1032 (20.4%)
5- Highest	9922 (21.4%)	9176 (19.2%)	1022 (20.2%)

Geographic data
Rural residence, n (%)	4896 (10.6%)	6403 (13.4%)	582 (11.5%)

Comorbidity

0–1	322 (0.7%)	380 (0.8%)	47 (0.9%)
2–3	3187 (6.9%)	2904 (6.1%)	352 (7.0%)
4–6	14 414 (31.1%)	13 746 (28.8%)	1440 (28.5%)
7+	28 395 (61.3%)	30 743 (64.4%)	3214 (63.6%)

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S16.

POD-04.05: 2016 Prize Essay Competition Winner: Clinical Science A prospective evaluation of obesometric parameters associated with renal stone recurrence

Derek Bos ¹, Shawn Dason ¹, Edward D Matsumoto ¹, Jehonathan Pinthus ¹, Christopher B Allard ^1,^2,³

Abstract

Introduction and Objectives:

To evaluate whether obesometric serum hormones and body fat distribution are associated with renal stone (RS) recurrence.

Methods:

Prospective cohort study of participants undergoing RS intervention at a single institution from November 2009-June 2010 and followed for median 62 months. Obesometric parameters were measured at baseline, including body mass index (BMI), fasting serum leptin and adiponectin, and proportion of visceral adipose tissue (%VAT) averaged from three fixed axial computed tomography (CT) slices. The primary study outcome was stone recurrence.

Results:

A total of 110 participants were enrolled. Elevated %VAT was associated RS recurrence; participants with %VAT in the highest quartile had five-year stone-free rate 47.1% compared to 72.2% among other participants (p=0.004). Adjusting for gender, elevated %VAT was independently predictive of RS recurrence among initial stone formers (N=74; HR 4.53, 95% CI 1.08–19.02), but not among recurrent stone formers (N=19; HR 0.51, 95% CI 0.054–4.72). Other obesometric factors, including leptin, adiponectin, and BMI, were not significantly predictive of recurrence.

Conclusions:

We report a novel association between an elevated proportion of visceral adipose tissue and stone recurrence. These findings may inform patient counselling and followup regimens. The metabolic basis for these findings requires further investigation.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S17.

MP-01.01: Percent Gleason pattern 4 on prostate biopsy in patients with Gleason 7 (3 + 4) prostate cancer does not predict upstaging to T3/T4 at radical prostatectomy

Nathan Perlis ¹, Rashid Sayyid ¹, Antonio Finelli ¹, Girish S Kulkarni ¹, Robert J Hamilton ¹, Alexandre Zlotta ¹, John Trachtenberg ¹, Andrew Evans ², Theodorus Van Der Kwast ², Sangeet Ghai ³, Neil E Fleshner ¹

Abstract

Introduction and Objectives:

Gleason (GL) score on prostate biopsy and radical prostatectomy (RP) specimens is a strong predictor of survival in patients with prostate cancer (PC). Patients with GL7 (3 + 4) on biopsy are known to have worse PC-specific survival than those with GL6 (3 + 3) and better outcomes than patients with GL7 (4 + 3). Relative volume of GL 4 vs. GL 3 in prostate biopsies is now routinely reported, but its effect on outcomes is unclear. To explore this, we assessed the predictive power of percent GL4 for adverse pathologic events at RP.

Methods:

Cases were collected from January 2008 to August 2015. Patients with GL6 or GL7 (3 + 4) on pre-RP biopsy were assessed and we explored clinicopathologic predictors of adverse pathology on RP defined as: extra-capsular extention (ECE), seminal vesicle (SVI), or bladder neck invasion (BNI). For men with GL 7 (3 + 4) on biopsy, we then evaluated the association between percent GL4 and adverse RP pathology. Univariable and multivariable logistic regression was performed using SPSS.

Results:

1475 RPs were performed on biopsy-proven GL6 or GL7 (3 + 4) PC from 2008 to 2015; detailed biopsy data, including percent GL4 was available for 776/931 patients with GL7 (3 + 4). Median patient age for the entire cohort was 61 years (interquartile range (IQR) 55–65) and pre-RP prostate-specific antigen (PSA) was 5.5 ng/ml (IQR 4–7.9). ECE, SVI, and BNI were present in 27.9%, 4.1%, and 3% of the cohort, respectively. On multivariable analysis, patients with GL6 vs. 7(3 + 4) had 40% less odds of upstaging to pT3 or pT4 on RP when taking into account age, PSA, percent positive cores, and clinical stage (OR 0.6, 95% CI 0.43–0.82, p=0.002). For patients with GL7 (3 + 4), the percent GL4 score was not predictive of poor pathologic outcomes.

Conclusions:

Percent GL4 does not appear to discriminate those patients with GL 7 (3 + 4) PC with adverse pathological findings on RP. GL4 may not be a reliable indicator of patients who will succeed active surveillance or focal therapy for PC.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S17.

MP-01.02: Time of occurence of metastasis influences overall survival in treatment-naïve prostate cancer

Sebastian Frees ¹, Shusuke Akamatsu ¹, Kenny Lynch ¹, Claudia Chavez-Munoz ¹, S Larry Goldenberg ¹, Peter C Black ¹, Martin E Gleave ¹, Kim Chi ¹, Alan I So ¹

Abstract

Introduction and Objectives:

Novel therapies have evolved the way to treat advanced prostate cancer. However, patients eventually die from metastatic disease. Little is known about the impact of time of occurrence of metastasis on overall survival (OS). Therefore, we divided patients with metastatic prostate cancer into three groups: 1) patients who presented with metastasis within three months of initial diagnosis (de novo-M); 2) patients who were free of metastasis initially, but developed metastasis more than six months prior to castration resistance (castration-sensitive prostate cancer with metastasis-CSPC-M); 3) patients who developed metastasis within six months of becoming castration-resistant or after (castration-resistant prostate cancer with metastasis-CRPC-M). Our objective was to clarify the impact of the timing of metastasis on OS.

Methods:

From 2008 to 2015, we identified 169 prostate cancer patients treated in our service. These patients included 69 de novo-M, 44 CSPC-M, and 56 CRPC-M. We analyzed patients’ characteristics and OS.

Results:

After a median followup of 5.86, 10.97, and 12.57 years for de novo-M, CSPC-M, and CRPC-M, respectively, 34.8% of patients with de novo-M, 47.7% in CSPC-M, and 44.6% in CRPC-M had deceased. There was a significant decrease in OS when metastases were present at diagnosis (median 5.72 years) compared to patients with CRPC-M (11.2 years) and a trend to better survival than CSPC-M (9.55 years). The difference observed in time to metastasis between CSPC-M and CRPC-M did not lead to a difference in OS. De novo-M showed a longer survival from occurrence of metastasis to death when compared to CSPC or even CRPC, although reaching a castration-resistant stage earlier than the other groups.

Conclusions:

Our results suggest that timing of the development of metastasis and corresponding initiation of treatment are important prognostic factors. Early intervention and diagnosis of M1 disease is important in advanced prostate cancer.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S18.

MP-01.03: Impact of visceral fat volume and fat density on biochemical outcome after radical prostatectomy and postoperative radiotherapy

Daniel Taussky ¹, Michel Zimmermann ¹, Maroie Barkati ¹, Shanie Campeau ¹, Denis Rompotinos ¹, Guila Delouya ¹

Abstract

Introduction and Objectives:

To assess the predictive value of visceral adipose tissue (VAT) and adipose tissue density after both radical prostatectomy (RP) and adjuvant or salvage external beam radiotherapy (EBRT).

Methods:

We randomly selected 201 patients treated with RP and EBRT between 2005 and 2015. VAT and subcutaneous adipose tissue volumes were manually contoured and corresponding tissue densities in Hounsfield units (HU) calculated. Time to biochemical recurrence (BCR) was calculated using the Kaplan-Meier method and comparisons were made using the log-rank test. Cox regression analysis was done for multivariate analysis.

Results:

Median time to BCR or last followup was 32 months. In univariate analysis for BCR, VAT volume and fat density were both associated with a better outcome (p=0.025 and p=0.024, respectively), as well as seminal vesicle involvement (p=0.024). Body mass index (BMI) was not predictive of BCR (p=0.32). In a multivariate model including seminal vesicle involvement, both a VAT volume above the median (HR 2.5, 95% CI 1.1–5.7; p=0.03) and a VAT density (HR 2.4, 95% CI 1.1–5.1; p=0.028) above the median remained predictive for a better biochemical outcome. Adjusting for BMI did not significantly change the model.Only when the model included all risk factors grouped together according to the CAPRA-S did the VAT volume (p=0.93) and VAT density (p=0.75) lose their predictive value. No correlation between adipose tissue volume or density and diabetes were found (p>0.4), but there was a statistically significant difference (p=0.03) in the mean VAT volume when comparing the 18 patients on metformin (25.8 cc; SD: 18.8 cc) vs. patients without metformin treatment (18.0 cc; SD: 13.9 cc). Neither subcutaneous fat (SAT) volume nor SAT density was predictive of biochemical outcome (p=0.5 and p=0.7, respectively).

Conclusions:

In both univariate and multivariate analysis, patients with both a larger VAT volume and density had a better biochemical outcome. The interaction between prostate cancer aggressiveness and visceral fat volume and density needs to be further evaluated to provide a better understanding of this disease.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S18.

MP-01.04: Justifying resources used for multiparametric magnetic resonance imaging with transrectal ultrasound targeted prostate biopsy (MRI/TRUS-TB) in a district general hospital

Emma Papworth ¹, Nick Burns-Cox ¹, Angus MacCormick ¹, Faisal Khan ¹

Abstract

Introduction and Objectives:

Evidence is emerging to support the use of magnetic resonance imaging with transrectal ultrasound (MRI/TRUS)-targeted biopsy (TB) for detection of clinically significant prostate cancer (csPCa).¹^,² In our trust, MRI/TRUS-TB has significantly increased the workload for histopathologists, necessitating justification for use of this biopsy technique. We compare the clinical significance and the National Institute for Health and Care Excellence (NICE) risk group classification³ of each tumour when reviewing histology from systematic TRUS-guided biopsy (STB) and TB results separately. According to NICE recommendations, the NICE risk group classification of a tumour significantly affects the management of patients with prostate cancer.

Methods:

Each patient underwent a 10-core systematic prostate biopsy in addition to a 2–4-core TB for suspicious MRI lesions. 53 MRI/TRUS-TBs from March 2014 to December 2015 were included in the analysis. Histological outcomes of STB, TB, and combined outcome were recorded. MRI/TRUS-TB accounted for 53/385 (14%) of all prostate biopsies within this period.

Results:

Detection rates for csPCa increased with addition of MRI/TRUS-TB (STB 32/53, 60 %; TB 33/53, 62%; combined 38/53, 72%). Some csPCa was missed by STB or TB alone. The NICE risk group classification³ was increased in some patients when TB and STB results were reviewed (higher risk TB than STB 7/42, 17%; same risk 31/42, 74%; higher risk STB than TB 5/42, 12%). The addition of TBs led to a 29% (12/42) increase in the final NICE risk group classification³ and Gleason upgrading in 36% (15/42).

Conclusions:

In our trust, TB combined with STB increased NICE risk group classification³ in 29% of patients, and upgraded Gleason grade in 36%. This difference in biopsy outcome would alter the management advice given to these patients. Targeted biopsies of suspicious areas on MPMRI are justified, as they affect the management of patients with prostate cancer.

References

1.Bacoa E, Rudb E, Eria LM, et al. A randomized, controlled trial to assess and compare the outcomes of two-core prostate biopsy guided by fused magnetic rsonance and transrectal ultrasound images and traditional 12-core systematic biopsy. Eur Urol. 2016;69:149–56. doi: 10.1016/j.eururo.2015.03.041. [DOI] [PubMed] [Google Scholar]
2.Moore CM, Robertson NL, Arsanious N, et al. Image-guided prostate biopsy using magnetic resonance imaging-derived targets: A systematic review. Eur Urol. 2013;63:125–40. doi: 10.1016/j.eururo.2012.06.004. [DOI] [PubMed] [Google Scholar]
3. NICE guidelines [CG175]. Prostate cancer: Diagnosis and management. Staging: 1.2.12. Published date: January 2014. www.nice.org.uk/guidance/cg175/chapter/1-Recommendations#assessment-2. Accessed April 14, 2016.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S18–S19.

MP-01.05: Prostate cancer patients’ preferences for information and decision support: Where, when, and how?

Deb Feldman-Stewart ¹, Christine Tong ¹, Michael D Brundage ¹, John Robinson ², Jackie Bender ³, Hannah Carolan ⁴, LK Joseph Chin ⁵, Joyce Davison ⁶, Arminee Kazanjian ⁷

Abstract

Introduction and Objectives:

We aimed to determine the population of prostate cancer patients’ preferences for information and decision support: where, when, and how.

Methods:

Surveys were conducted in British Columbia, Alberta, and Saskatchewan in 2014 and 2015. A random sample of 55% of the prostate cancer patients in each provincial registry diagnosed in late 2012 was surveyed.

Results:

Provincial response rates were 46–55%, total N=1007. Across provinces, mean age was 69 years. Between diagnosis and treatment decision, preferred information sources were urologists (90%), family physicians (85%), and radiation oncologists (58%); 73% wanted printed information and 58% wanted it on the internet. Barriers to obtaining information from physicians included not having enough time (27%), worrying about time (21%), and worrying about asking too many questions (15%). Barriers to obtaining information from books/internet, respectively, included uncertain quality (37/46%), unclear if personally applicable (39/41%), and poor search skills (31/20%). Recommended facilitators for providing information included a person to guide its acquisition (71%), providing printed information (69%), and someone to answer questions: in person (77%), over the phone (53%), or via email (43%). Even if access was easy, 27% would not want information from the internet and 13% would not want any printed information. Regarding decision-making, 18% would have liked more help with their decision, though half of that group (53%) felt well-informed. 77% of all respondents either used decision support or would have wanted to if they had known about it. Recommended timing for decision support included before meeting any specialists (11%), at the urologist visit (31%), and after all specialist visits before the decision is made with a doctor (35%).

Conclusions:

Most prostate cancer patients want information and decision support, but vary in where, when, and preferred medium. Optimal support needs to be multifaceted and flexible, with urologists playing a central role.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S19.

MP-01.06: Testosterone replacement therapy in patients with known prostate cancer: Impact on oncologic outcomes

Jesse Ory ^1,², Ryan Flannigan ¹, Colin Lundeen ¹, James G Huang ^1,³, Peter J Pommerville ¹, S Larry Goldenberg ¹

Abstract

Introduction and Objectives:

Both hypogonadism and prostate cancer have increasing prevalence with age. However, because of the relationship between prostate cancer and androgen receptor activation, testosterone replacement therapy (TRT) among patients with known prostate cancer has been approached with caution. We seek to add to the growing body of literature on the safety of TRT in this setting with one of the largest multimodal reviews of men treated with TRT following localized treatment or active surveillance (AS) for prostate cancer.

Methods:

We identified a cohort of 83 hypogonadal men with prostate cancer who were treated with TRT. These included 50 men treated with radiation therapy (RT), 22 with radical prostatectomy (RP), eight with AS, one with cryotherapy, and one with high-intensity focused ultrasound (HIFU). We evaluated changes in prostate-specific antigen (PSA), testosterone, hemoglobin, the rate of biochemical recurrence (BCR), and PSA velocity (PSAV).

Results:

Median patient age was 75.5 years and median followup was 41 months. We found an increase in both testosterone (p<0.001) and PSA (p=0.001) levels in the entire cohort, but when analyzed by risk group, only low-risk prostate cancer patients had a statistically significant increase in their PSA (p=0.006). PSA did also increase in the AS patients, however, no patients were upgraded to higher Gleason score on subsequent biopsies, and none have yet gone on to definitive treatment. We did not have any cases of BCR among RP patients, but three RT patients (6%) experienced BCR by 2006 Phoenix criteria.¹ It is unclear whether these were related to TRT or reflected the natural biology of their disease. We calculated the mean PSAV to be 0.001, 0.12, and 1.1 ug/L/yr for the RP, RT, and AS groups, respectively.

Conclusions:

Our study supports the hypothesis that TRT is oncologically safe in hypogonadal men following definitive prostate cancer treatment, as well as those on AS of low-risk cancer.

Table 1.

MP-01.06. TRT and PSA parameters in 83 patients with CaP classified by primary treatment modality and D’Amico risk stratification

Type of treatment	D’Amico risk	n	Time Rx to TRT (median months)	Duration TRT (median months)	Initial median T (mmol/L)	Final median T (mmol/L)	Initial PSA (median)	Final median PSA	Median PSAV (ng/ml/yr)	BCR (%)
Radical prostatectomy	All	22	15	48	6.60	13.3	undetectable	undetectable	0	none
	Low	3	33	55	6.2	11.75	undetectable	0.016	0.0014	none
	Intermediate	11	13	37.7	7	15.4	undetectable	undetectable	0	none
	High	8	15	59.5	6.25	15.1	undetectable	undetectable	0	none
Radiotherapy	All	50	45	36.5	6.25	13.05	0.125	0.18	0.0175	6.00%
	Low	10	61	40	7	15.5	0.185	0.145	0.0039	5.26%
	Intermediate	19	42	47	6.95	10.6	0.06	0.062	0	0.00%
	High	21	43	23	5.6	14.7	0.18	0.49	0.1025	9.52%
Active surveillance	Low	8	n/a	33	5.2	15.5	3.9	5.2	0.51	NA
HIFU	Low	1	4	42	5	1.3	0.26	1.2	0.31
Cryotherapy	High	1	17	9	4.9	NA	1.1	3.2	0.8

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References

1.Roach M, 3rd, Hanks G, Thames H, Jr, et al. Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: recommendations of the RTOG-ASTRO Phoenix Consensus Conference. Int J Radiat Oncol Biol Phys. 2006;65:965–74. doi: 10.1016/j.ijrobp.2006.04.029. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S20.

MP-01.07: Prognostic factors in radical prostatectomy and permanent seed brachytherapy for low- and intermediate-risk prostate cancer: A comparative study

Daniel Taussky ¹, Véronique Ouellet ², Guila Delouya ¹, Fred Saad ³

Abstract

Introduction and Objectives:

To compare the outcomes between radical prostatectomy (RP) and permanent seed prostate brachytherapy (PB) in patients with low- and low-intermediate-risk prostate cancer from a single tertiary care centre.

Methods:

Patients were selected from our institute’s internal database, based on preoperative selection criteria from the NCCN guidelines (2015) for low- and intermediate-risk patients. No patient had received any neo-adjuvant androgen-deprivation therapy. The endpoint was biochemical recurrence (BCR) or any salvage treatment for both RP and PB at 48 ± 4 months after treatment. The biochemical relapse threshold was set at prostate-specific antigen (PSA) ≥0.5 ng/mL for PB, and two PSA values of ≥0.2ng/mL for RP. Patients from both treatment groups were compared using non-parametric tests. A binary logistic regression analysis was performed to determine an association of treatment and pretreatment factors with a BCR at 48 months.

Results:

575 patients were included in this study; 254 were treated with RP and 321 with PB. Patients treated with RP were younger (mean 61 years vs. 64 years) and more likely to have cT1-stage cancers (83% vs. 73% for PB), but had a higher mean percentage of positive biopsies (44% vs. 34% for PB) and were more likely to be diagnosed with a Gleason 7 score (30%) than patients treated with PB (20%). BCR occurred in 54 patients (21.2%) in the RP group and in 66 patients (20.6%) in the PB group (p=0.24, Chi-square test). Based on univariate and multivariate logistic regression analyses, younger age, higher percentage of positive biopsies and initial PSA were predictive of BCR. Treatment modality was not predictive in either univariate (p=0.56) or multivariate (p=0.42) analyses.

Conclusions:

Using closely related cut-off values for BCR, both RP and PB appear to result in equal outcomes at four years post-treatment.Clinical T-stage, age, percentage of positive biopsies, and Gleason score were predictive of BCR.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S20.

MP-01.08: Cancer control outcomes of robot-assisted radical prostatectomy for high-risk, clinically localized prostate cancer: Prospective analysis of 124 consecutive men from the University of Alberta

Jan K Rudzinski ¹, Eric Estey ¹, Sunita Gosh ², Niels-Erik B Jacobsen ¹, Adrian S Fairey ¹

Abstract

Introduction and Objective:

Approximately 20–30% of men are diagnosed with high-risk, clinically localized prostate cancer (HR-CLPC) at initial presentation. Radical prostatectomy and external beam radiation therapy with androgen-deprivation are standard primary treatment options for HR-CLPC. Over the past decade, robot-assisted radical prostatectomy (RARP) has supplanted open radical prostatectomy as the preferred surgical approach. However, limited data are available examining the efficacy of RARP for HR-CLPC. Our aim was to examine cancer control and perioperative outcomes in men who underwent RARP for HR-CLPC.

Methods:

A prospective analysis of data from the University of Alberta Radical Prostatectomy Database was performed. Between September 2007 and January 2013, 124 consecutive men underwent RARP for D’Amico classification HR-CLPC. Cancer control outcomes were biochemical recurrence (BCR) and salvage therapy (ST) rates. BCR was defined as a prostate-specific antigen (PSA) ≥0.2 ug/l, followed by a subsequent confirmatory value or initiation of ST. ST was defined as receipt of radiation therapy (RT) or hormone therapy (HT) >6 months after surgery and/or in the presence of BCR. Perioperative outcomes were 90-day complication and health care utilization rates. The Kaplan-Meier method was used to estimate BCR and ST. Multivariable Cox regression analysis was used to determine predictors of BCR. Statistical tests were two-sided (p<0.05).

Results:

Evaluable data were available for 124 men (100%). The median followup duration was 37.9 months (range 0.4–82.7 months). Mean age and body mass index (BMI) were 61.9 years (range 47.0–78.0 years) and 29.1 kg/m² (range 18.1–45.0 kg/m²), respectively. 83 men (67%) had preoperative biopsy composite Gleason score ≥8. 114 (92%) and 100 (81%) men had >pT2c and pN0 disease, respectively. The five-year freedom from BCR rate was 65.0%. The five-year freedom from ST rate was 75.1%. Multivariable Cox regression analysis showed that pTstage and pNstage were independently associated with BCR (≤pT2 vs. ≥pT3: HR 0.32, 95% CI 0.15–0.69; p=0.004; pN0 vs. pN1; HR 0.23; 95% CI 0.10–0.54; p<0.001). No patient (0%) required blood transfusion. 29 patients (23%) experienced one or more complication within 90 days of surgery. 20 (16%) and one (1%) patients returned to the emergency room and were readmitted to hospital within 90 days of surgery, respectively.

Conclusions:

RARP conferred acceptable intermediate-term cancer control and perioperative outcomes for men with HR-CLPC. These data support the continued use of RARP for HR-CLPC. Extended followup of this cohort with assessment of clinical endpoints is needed.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S20.

MP-01.09: Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon

Shawn Dason ¹, Anthony Adili ¹, Julia Di Giovanni ¹, Emma Kolesar ¹, Bobby Shayegan ¹

Abstract

Introduction and Objectives:

Experience with laparoscopic radical prostatectomy (LRP) is hypothesized to hasten the robot-assisted laparoscopic radical prostatectomy (RARP) learning curve. In this study, we describe the positive surgical margin (PSM) rates, as well as other outcomes during the RARP learning curve of a single surgeon with significant prior LRP experience.

Methods:

Participants were consecutively enrolled from March 2012 to April 2015 if they underwent RARP by a single surgeon. The RARP procedure was performed with a standardized transperitoneal technique and the RARP postoperative course followed a standardized clinical pathway. The primary outcome of this study was the impact of case quartile on margin status. Multivariate logistic regression of case number relative to margin status was performed, with established predictors of margin rates included as co-predictors (T3 stage, prostate-specific antigen (PSA), body mass index (BMI), and prostate weight). Secondary outcomes included the impact of case quartile on pT2 and pT3 PSM rates, operative time, estimated blood loss, and length of hospital stay. The most recent quartile was used as the reference standard. Odds ratios and t-testing were used where appropriate and statistical significance was defined as p<0.05.

Results:

A total of 400 consecutive patients were included in this study, with a median patient age of 63.8 years and a median PSA of 6.9 ng/ml. Overall mean operative duration was 187.2 minutes and mean estimated blood loss was 240.9 ml. A total of 157/400 (39%) patients had pT3 disease and the remainder (243/400, 61%) had pT2 disease. There were 82 positive margins. The pT3 PSM rate was 33.3% and the pT2 PSM rate was 11.9%. The first quartile of cases had an odds ratio for overall, pT3, and pT2 positive margins of 1.74 (95% CI 0.90–3.36; p=0.1), 1.45 (0.62–3.41; p=0.39), and 1.69 (95% CI 0.62–4.58; p=0.30) respectively. When looking at the second or third quartiles relative to the most recent quartile, no significant differences were noted. Multivariate logistic regression suggested that case number did not predict probability of PSM (Exp[B]=0.998, 95% CI 0.994–1.002; p=0.3). The first quartile operative time was a mean of 207.4 minutes, decreasing to 179.2 by quartile four (p<0.0001). The first quartile estimated blood loss was a mean of 255.1 ml and this decreased to 213.6 ml by quartile four (p=0.0064).

Conclusions:

Even when controlling for co-predictors, a statistically significant learning curve for PSM rate was not demonstrated in this study. We hypothesize that previous LRP experience may reduce the RARP PSM learning curve.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S21.

MP-01.10: The use of graphical displays of quality of life information to improve patient understanding when deciding on prostate cancer treatment

Jason P Izard ^1,^2,³, Christine Tong ³, Deb Feldman-Stewart ^2,³, Michael D Brundage ^2,³

Abstract

Introduction and Objectives:

In prostate cancer, treatment-related decisions are complex and may impact post-treatment quality of life (QOL). Decision aids for patients have been shown to be effective in preparing patients for treatment-related decision-making and in reducing post-decisional regret. Additionally, pictographs have been shown to increase understanding of medical information. We investigated the use of two different graphical displays of QOL information in the context of a prostate cancer decision aid.

Methods:

Patients with low- and intermediate-risk, localized prostate cancer were recruited for study participation. A previously studied decision aid was adapted to include QOL data displayed via a line graph showing temporal trends and a pictograph showing proportional risks of QOL impairment. In a semi-structured interview, participants used Likert scales to rate graphical information formats with respect to usefulness and ease of understanding. They were then asked to verbally explain the information to a third party to judge understanding. Single-sample and paired t-tests were used to evaluate responses.

Results:

Participants found both graphical formats useful and easy to understand. Differences between mean subjective usefulness ratings (9.1 vs. 8.2; p=0.13) and mean subjective understanding ratings (9.5 vs. 9.0; p=0.26) of pictograph and line graph formats did not reach statistical significance. Third-party assessment of patient understanding of the informational content also did not differ significantly between graphical formats (p=0.36). Common themes from qualitative feedback include the feeling of being overburdened with information and the possible preference of pictograph information over “scientific” line graphs, with the preference to review line graphs if desired.

Conclusions:

Graphical displays of health information may assist in patient understanding and decision-making with patients’ preferences possibly favouring pictographs of proportional risk.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S21.

MP-01.11: Impact of posterior urethrovesical reconstruction on early return to continence after robot-assisted radical prostatectomy: A randomized, controlled trial

Christopher H Wu ¹, Jen Hoogenes ¹, Lisa Patterson ¹, Edward D Matsumoto ¹, Bobby Shayegan ¹

Abstract

Introduction and Objectives:

Urinary incontinence post-radical prostatectomy has a significant negative impact on quality of life. As 12-month continence rates range from 85–95%, few patients are continent in the early postoperative period. Posterior reconstruction (PR) of Denonvilliers’ musculofascial plate may improve early return to urinary continence, though prior studies have shown mixed results, with varied definitions of continence, differing surgeon experience, lack of randomization, and insufficient statistical power. We compared the PR vs. conventional anastomosis during robot-assisted radical prostatectomy (RARP) in a randomized, controlled trial (RCT).

Methods:

Patients with localized prostate cancer scheduled for RARP were prospectively recruited and randomly allocated to PR or conventional anastomosis. Patients were blinded and the surgeon was informed just prior to the case to minimize bias. All cases were performed by a single high-volume surgeon at a tertiary centre. The Expanded Prostate Cancer Index Composite Short Form (EPIC-26) survey was used at baseline and two, three, four, six, eight, and 12 months postoperatively. Continence was defined as 0–1 safety pads per day. The trial is powered to detect a significant improvement in continence of 40–75% at three months. Followup interviews were done via telephone.

Results:

Recruitment occurred from April 2014 to July 2015, with a total N=164. Six-month followup data are available on 55 patients in the PR group and 42 in the control group. At two, three, four, and six months, use of pads for the intervention group and the control group at 0–1 per day (continence) was 36.5% and 37.5%, 60.7% and 60.5%, 72.6% and 65.7%, and 83% and 76.5%, respectively.

Conclusions:

Interim analysis of this RCT suggests a trend towards PR being more effective than conventional anastomosis in terms of early return to continence following RARP, especially approaching the fourth month. Continuing analysis of patient followup and completion of the trial is required to establish statistical significance of these findings.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S21–S22.

MP-01.12: First results of a new tool for evaluating of cavernous body fibrosis after radical prostatectomy: Penile elastography

Nurullah Hamidi ¹, Namik K Altinbas ², Evren Suer ¹, Mehmet I Gokce ¹, Cemil Yagci ², Kadir Turkolmez ¹

Abstract

Introduction and Objectives:

It is believed that the main cause of erectile dysfunction following radical prostatectomy (RP) is cavernous tissue fibrosis depending on neurovascular bundle (NVB) damage. We aimed to evaluate the changes in cavernous tissue elasticity scores in patients who underwent RP with NVB preserving or not.

Methods:

We prospectively collected data of 65 preoperative potent patients who underwent RP for organ-confined prostate cancer at our institution between April 2014 and March 2015. Patients were divided into three groups: non-nerve-sparing (Group 1=22 patients); unilateral (left/right) nerve-spared (Group 2=22 patients); and bilateral nerve-spared (Group 3=21 patients). Preoperative and postoperative (third and sixth month) International Index of Erectile Function (IIEF)-5 and elasticity scores were recorded. Elasticity of cavernous tissue (at level of penoscrotal junction) was assessed with real-time elastography. All elastography measures were performed by a single radiologist between 0–6 scores (0:elastic, 6:fibrotic).

Results:

Age, preoperative IIEF-5, and elasticity scores were similar for all three groups (p=0.22, p=0.54, p=0.36, respectively). The differences of postoperative IIEF-5 and elasticity scores between Groups 1 and 2 and Groups 1 and 3 were statistically significant. However, difference between Groups 2 and 3 was not statistically significant. Postoperative IIEF-5 and elasticity scoreswere at three and six months are summarized in the tables on the right-hand side of Fig. 1. Also a very strong negative correlation was detected between IIEF-5 and elasticity scores in Spearman correlation test at postoperative Month 3 (r=−0.818) and 6 (r=−0.814).

Conclusions:

Lower IIEF-5 and higher elasticity (in favour of fibrosis) scores were observed in bilateral non-nerve-sparing patients after RP. Preserving NVB in at least one side mediates better IIEF scores and lower elasticity scores. Preliminary results of the penile elastography studies are promising for prediction of erectile functions and cavernous tissue fibrosis. Further prospective studies are necessary for confirmation of our results.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S22.

UP-01.01: Effects of dietary omega-3 fatty acids on tumour growth and immune response in the TRAMP-C2 prostate tumour model in castrated mice

Nikunj Gevariya ^1,², Alain Bergeron ^1,², Karine Robitaille ^1,², Marjorie Besançon ^1,², Valérie Picard ^1,², Yves Fradet ^1,², Vincent Fradet ^1,²

Abstract

Introduction and Objectives:

Inflammation is a contributing factor to prostate cancer (PCa) development. Dietary omega (Ω)-3 fatty acids (FA) reduce tumour growth likely by affecting the immune response in an immune-competent TRAMP-C2 PCa mice model. However, it remains unclear if that effect remains in the context of androgen deprivation. Our objectives were to measure the effects on tumour growth an intratumoural immune response of dietary Ω-3 FAs using the TRAMP-C2 PCa model in castrated mice.

Methods:

Groups of 15 C57BL/6 mice were fed with Ω-3- or Ω-6-enriched diets until sacrifice. After two weeks of diet, all mice were surgically castrated and two weeks after castration, 2×10⁶ TRAMP-C2 cells were implanted s.c. on each flank. Mice were sacrificed when the tumour volume reached 2 cm³. Plasma, red blood cells, and tumours were collected at sacrifice. The FA profiles were determined by capillary gas-liquid chromatography, and cytokine profiles by Luminex assays. Finally, immune-cell infiltration was analyzed in dissociated tumours using multicolour flow cytometry. Survival analysis was used to estimate time to sacrifice. Intratumoural levels of cytokines and immune cells were compared using the Mann-Whitney test, with p-values <0.05 declared significant.

Results:

Tumours of the Ω-3-treated mice had a slower growth than Ω-6-treated mice tumours and survival time of mice was improved (log rank p=0.0004). FA profile showed substantial incorporation of Ω-3 FAs in the tumours of Ω-3- vs. Ω 6-treated mice. Granulocyte-macrophage colony-stimulating factor (GM-CSF) was detected in 1/3 of Ω-3-treated mice tumours and none of in the Ω-6-treated mice. IL4, IL5, IL10, IL12(p70), MCP-1, MIP-1b, and TNF-α were expressed at significantly higher level in Ω-3 group. CD4⁺ IL-10⁺ and CD4⁺ IL4⁺ cells were significantly more abundant in Ω-3 mice tumours compared with tumours in Ω-6 mice.

Conclusions:

Dietary Ω-3 FAs reduce prostate tumour growth in this castrated, immune-competent mice model. This could be achieved by favouring a more effective immune response.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S22.

UP-01.02: Re-examining the administration of prophylactic ciprofloxacin prior to transrectal ultrasound-guided prostate biopsies at a tertiary academic Canadian hospital

Nathan C Wong ¹, Aalok Shah ¹, Camilla Tajzler ¹, Anil Kapoor ¹

Abstract

Introduction and Objectives:

Recently, there has been an increase in bacterial resistance to ciprofloxacin, encouraging exploration of other prophylactic antibiotic regimens prior to transrectal ultrasound (TRUS)-guided prostate biopsies. We performed a retrospective analysis of patients who underwent a TRUS biopsy at our tertiary academic Canadian hospital to examine infection rates comparing ciprofloxacin only to other antibiotic therapies.

Methods:

A retrospective chart review was performed between 2013 and 2015 of men who underwent TRUS biopsy. Of the 382 charts reviewed, 71 patients were excluded due to insufficient data, leaving a study cohort of 311 patients. Demographic data, prostate-specific antigen (PSA), prostate volume, and complications, particularly post-TRUS sepsis within 30 days, were ascertained from electronic records. We compared infection rates of patients who were given ciprofloxacin (Group 1) vs. other regimens (Group 2).

Results:

The average age of the patients was 64 years with a mean PSA of 7.2 ng/mL and prostate volume of 42.3 cc. Approximately 84.9% of patients (Group 1: 264/311) were given ciprofloxacin only prophylaxis prior to TRUS biopsy. The rest of the patients (Group 2: 47/311) were given other antibiotics, including tobramycin, gentamycin, septra, ampicillin, and/or vancomycin with or without concurrent ciprofloxacin. Overall rate of sepsis was 3.22%. Sepsis rates for Group 1 and Group 2 were 3.79 and 0%, respectively (p<0.05). The majority of those who developed bacteremia in Group 1 grew organisms resistant to ciprofloxacin. There were no other serious post-biopsy complications noted.

Conclusions:

At our centre, the rate of post-TRUS biopsy sepsis in patients receiving ciprofloxacin only compared to other antibiotic regimens was statistically higher. Consideration should be given to using alternative antibiotics, to evaluate local patterns of antibiotic resistant organisms and change practice accordingly, or to performing routine rectal swabs to identify at-risk individuals.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S22.

UP-01.03: Effects of chronic lung disease and smoking on prostate cancer mortality after radical prostatectomy

Tal Ben-Zvi ^1,², Moliere Nguile-Makao ², Marc-Andre Allard ^1,², Louis Lacombe ^1,², Yves Fradet ^1,², Vincent Fradet ^1,²

Abstract

Introduction and Objectives:

Faced with an aging population and associated patient comorbidities, urologists are confronted with the dilemma of risk stratification in identifying higher-risk patients being followed for prostate cancer (PCa) post-radical prostatectomy (RP). Our objectives were to examine the associations between chronic obstructive pulmonary disease (COPD), smoking, and cause of mortality.

Methods:

Between 1987 and 2007, 2385 consecutive men were treated by RP at CHU de Québec. Charts were reviewed systematically. Cause of death was ascertained by chart review and validated with data from Quebec Statistical Institute. We used competing risks modeling with right censoring (Fine & Gray method) adjusted for age, prostate-specific antigen (PSA), stage, grade, and nodal involvement to estimate the risks (HR) of prostate cancer-specific mortality (PCSM) and other-cause mortality (OCM).

Results:

This cohort included 2385 men, with 57 (2.4%) PCSM and 302 (12.7%) OCM. Median survival time was 18 years (interquartile range (IQR) 16 years). All adjusted comparisons were made with non-smoking men without COPD. COPD significantly increased PCSM risk (HR 2.83, 95% CI, 1.3–6.4), but smoking in itself did not. Both types of COPD affected PCSM: COPD in men who never smoked (HR 6.7, 95% CI 1.4–32.2) and in current smokers (HR 5.1, 95% CI 1.3–19.6). However, PCSM was not affected in past smokers with COPD. Risk of OCM was increased by both COPD (HR 1.6, 95% CI 1.5–1.8) and smoking (HR 4.3 95% CI 3.7–4.9).

Conclusions:

Both smoking- and non-smoking (ever)-associated forms of COPD were significantly and independently associated with OCM, as expected, but additionally with PCSM in this cohort. Moreover, smoking cessation appears to reverse the risks of smoking-related COPD effects on PCSM. If validated, our findings would support a specific PCSM effect of smoking and smoking cessation post-RP. More research to is required at this time to identify the underlying mechanisms linking COPD and smoking to PCSM.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S23.

UP-01.04: CAPRA-S predicts outcome for adjuvant and salvage EBRT after radical prostatectomy

Daniel Taussky ¹, Guila Delouya ¹, Michel Zimmermann ¹, Abdullah M Alenizi ², Emad S Rajih ², Kevin C Zorn ²

Abstract

Introduction and Objectives:

To evaluate the predictive value of the Cancer of the Prostate Risk Assessment Postsurgical Score (CAPRA-S) for patients treated with radical prostatectomy followed by subsequent external beam radiotherapy (EBRT).

Methods:

A total of 373 patients treated with EBRT between January 2000 and June 2015 were identified in the institutional database. Followup and complete CAPRA-S scores were available for 334 (89.5%) patients. Median followup following EBRT was 48 months (interquartile range (IQR) 28–78); 12% received EBRT within four months of surgery. Concomitant androgen-deprivation therapy (ADT) was administered in 36.2% of cases. CAPRA-S scores were sorted into previously defined categories of low- (score 0–2), intermediate- (3–5), and high-risk (6–12). Time to biochemical recurrence (BCR) was defined as prostate-specific antigen (PSA) >0.20 ng/mL after EBRT. Survival analyses were performed using the Kaplan-Meier method and comparisons were made using the log-rank test.

Results:

Overall median time from surgery to EBRT was 18 months (IQR 8–36) and median followup since EBRT was 48 months (IQR 28–78). CAPRA-S predicted time to BCR (<0.001), time to palliative ADT (p=0.017), and a trend for significantly predicting overall survival (OS, p=0.058). Using predefined PSA categories before EBRT, we found that each rise to a higher group increases the hazard of BCR by 28.6% (HR 1.286; 95% CI 1.009–1.641). When evaluating the PSA before EBRT as a continuous variable, each increase of 1 ng/mL translated into a 20% increase risk of BCR (HR 1.199; 95% CI: 1.070–1.343).On multivariate analysis, the CAPRA-S was predictive of time to BCR only (low-risk vs. intermediate-risk; HR 0.14, 95% CI 0.043–0.48; p=0.001). The last PSA measurement before EBRT as a continuous and grouped variable proved highly significant in predicting all outcomes tested, including OS (p≤0.002).

Conclusions:

CAPRA-S predicts time to BCR and freedom from palliative ADT, and was borderline significant for OS. Together with the PSA before EBRT, CAPRA-S is a useful predictive tool. The main limitation of this study is its retrospective design.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S23.

UP-01.05: Pathological outcome at salvage prostatectomy for post-radiation adenocarcinoma with treatment effect

Michael Metcalfe ¹, Charles C Guo ², Hsiang C Chen ³, Yasar Bozkurt ¹, Louis L Pisters ¹

Abstract

Introduction and Objectives:

Prostate biopsies following localized radiation therapy for prostate cancer often demonstrate residual prostatic carcinoma with treatment effect, in which the malignant glands exhibit histologic features that are distinct from treatment-naïve prostate cancer. The final oncological outcome of prostatic adenocarcinoma with treatment effect is currently unknown. We set out to identify the pathological outcome for those with complete treatment effect (CTE) on post-local therapy biopsy who subsequently underwent salvage prostatectomy and relate this to oncological outcome.

Methods:

A single-centre, retrospective review of all salvage radical prostatectomies (SRP) performed at MDACC from 1995 to 2014 was performed. Biopsy results post-local therapy were stratified as CTE, partial treatement effect (PTE), or no treatment effect (NTE). They were compared to final pathology following salvage prostatectomy. Primary outcome was recurrence-free survival (RFS).

Results:

70 patients who had SRP met study criteria. 16 patients had CTE in the absence of other adenocarcinoma on biopsy. Among them, one (7%) patient had no evidence of carcinoma at time of salvage prostatectomy, four (27%) had adenocarcinoma with CTE, three (20%) had adenocarcinoma with minimal or PTE, and seven (47%) had adenocarcinoma with NTE. The median RFS was 2.78 years (95% CI, 0.81–5.43 years) and the five-year RFS rate was 37% (95% CI, 22%–52%). Number of positive cores at time of pre-salvage (p=0.01) and Gleason sum prior to salvage (p=0.03) were significantly associated with RFS. The presence of CTE was not predictive of RFS (p=0.12) (Fig. 1).

Conclusions:

In patients who have CTE on biopsy post-local therapy, less than one-third had concordant pathology at time of RP and 66.7% had radiation-resistant disease. The presence of CTE did not have effect on RFS. High biopsy Gleason grade and volume of disease was predictive of recurrence.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S23–S24.

UP-01.06: Haptic simulation of prostate surgical planning based on magnetic resonance elastography

David Zumba ¹, Cristian Luciano ¹, Simone Crivellaro ², Dieter Klatt ¹, Steven Kearney ³, Thomas Royston ¹

Abstract

Introduction and Objectives:

The average rate of positive margins in robotic-assisted laparoscopic radical orostatectomy is 15% (range 6.5–32%).¹ Improved preoperative planning could reduce the incidence of positive margins. Magnetic resonance elastography (MRE) has the potential to provide quantitative data of the tissue mechanical properties, linked to tumour malignancy.² The goal of this project is to develop a virtual reality haptic simulator that will improve pre-surgical planning and reduce the incidence of positive margins.

Methods:

A virtual 3D prostate model was created by scanning a plastic phantom (CIRS) with an ultra-high field 9.4 T Agilent horizontal bore preclinical magnetic resonance imaging (MRI) system (310/ASR), upgraded with MRE scanning capabilities. MRE data was obtained by inserting an acoustic source tube into the probe opening (rectum), and processed by performing full 3D Helmholtz direct inversion to the noise-filtered 3D wave displacement data.

Results:

A haptic device (3D Systems Touch^™ X) was used to explore the virtual prostate model. Haptic resistance was computed-based on the shear modulus map provided by the MRE data. It was found that regions of high stiffness obtained by MRE correspond well with the phantom lesions and urethra.

Conclusions:

The results of this preliminary study suggest the feasibility of using a novel combination of MRE and haptics to better identify prostate tumour locations and sizes, and more accurately perform cancer staging in patients with prostate cancer.

References

1.Yossepowitch O, Briganti A, Eastham JA, et al. Positive surgical margins after radical prostatectomy: A systematic review and contemporary update. Eur Urol. 2014;65:303–13. doi: 10.1016/j.eururo.2013.07.039. [DOI] [PubMed] [Google Scholar]
2.Hoyt K, Castaneda B, Zhang M, et al. Tissue elasticity properties as biomarkers for prostate cancer. Cancer Biomark. 2008;4:213–25. doi: 10.3233/cbm-2008-44-505. [DOI] [PMC free article] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S24.

UP-01.07: Comparing perspectives of men diagnosed with prostate cancer and healthcare professionals about active surveillance

Margaret Fitch ¹, Kittie Pang ¹, Veronique Ouellet ², Simone Chevalier ³, Darrel E Drachenberg ⁴, Antonio Finelli ⁵, Lucie Hamel ³, Jean-Baptiste Lattouf ¹, Kathy Li ⁵, Maureen Palmer ⁶, Paula Sitarik ⁴, Alan I So ⁶, Simon Sutcliffe ⁷, Simon Tanguay ³, Fred Saad ¹, Anne-Marie Mes-Masson ¹

Abstract

Introduction and Objectives:

The practice of active surveillance (AS) for men with low-risk prostate cancer (PCa) is growing across Canada. This study explored the perspectives of men diagnosed with PCa and healthcare professionals (HCP) regarding AS and the factors that influence the uptake of AS.

Methods:

Focus groups were held in several Canadian cities with men (seven groups, N=56) diagnosed with PCa and eligible for AS, and with HCPs (five groups, N= 48) who care for men with PCa and engage in conversations about AS. Viewpoints were captured regarding understanding of AS, practices regarding AS, and factors that influence decision-making about AS. A content analysis was performed on the verbatim transcripts and a comparison was made between the men’s and the HCP’s viewpoints.

Results:

Both men and HCPs agreed AS is for low-grade or low-risk disease, it has intent (“it is not about doing nothing”), it avoids treatment side effects, and the regular monitoring allows time for treatment if the disease changes. Both groups agreed that men could be accepting of AS if there was no change in disease status. Disease status was a key factor for clinicians and men in deciding to pursue AS. However, men discussed the importance of quality of life as a key consideration to balance in their decision-making. The differences in perspectives between men and clinicians became evident regarding clarity around criteria for AS, interpretation of test results, what constitutes a standard (best practice) approach for AS, clarity of information provided to patients, how much information is needed and given to men, as well as the amount of time required to make a decision.

Conclusions:

Differences in perspectives can be a source of tension and misunderstanding between patients and clinicians. Communication and education efforts are needed to achieve clear, shared perspectives on AS between men diagnosed with PCa and their physicians.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S24.

UP-01.08: Predictors for upgrading and upstaging of biopsy Gleason 3 + 4 prostate cancer at radical prostatectomy

Daniel T Keefe ¹, Trevor Flood ², Nicola Schieda ³, Luke T Lavallee ^1,⁴, Ilias Cagiannos ¹, Christopher G Morash ¹, Sonya Cnossen ⁴, Ranjeeta Mallick ⁴, Rodney H Breau ^1,⁴

Abstract

Introduction and Objectives:

Some patients with Gleason grade 3 + 4 prostate cancer may be safely managed with active surveillance. The purpose of this study was to identify predictors for upgrading or upstaging of biopsy Gleason grade 3 + 4 prostate cancer at radical prostatectomy.

Methods:

Consecutive patients with Gleason 3 + 4 on biopsy between January 2010 and December 2015 were identified. Patients who had both biopsy and radical prostatectomy at The Ottawa Hospital were included. Baseline clinical variables were identified from the medical record. Prostate biopsy specimens were re-reviewed by blinded genitourinary pathologists. The primary outcome was upgrading (grade 4 + 3 or higher), upstaging (pT3), or a composite of either upgrade or upstage from the prostatectomy specimen.

Results:

Of 154 patients who met inclusion criteria, 41 (27%) had palpable tumours and 115 (76%) had prostate-specific antigen (PSA) density of 0.15 or greater. Median PSA was 6.7 ng/ml (interquartile range (IQR) 5–9) and mean age was 63 years (SD 6.5). On blinded review of biopsy tissue, 11 (7%) had cribiform pattern and 57 (37%) had perineural invasion. The mean proportion of cores with any grade 4 tumour was 23% (SD 0.16), the mean proportion of all tissue that had prostate cancer was 18% (SD 13%) and the proportion of all tumour that was grade 4 was 14% (SD 12%). Median time between biopsy and radical prostatectomy was 108 days (IQR 84, 146 days). At prostatectomy, Gleason scores were upgraded to 4 + 3 or higher in 44 patients (29%); 69 (45%) patients were upstaged to pT3; and either of these outcomes was found in 84 (54%) patients. On multivariable analysis, statistically significant predictors of upgrading or upstaging included PSA density ≥0.15 (OR 2.9; 95% CI 1.1, 8.3) and proportion of cancer tissue with Gleason pattern 4 (OR 71; 95% CI 2.4, 2089).

Conclusions:

Some patients with Gleason grade 3 + 4 on biopsy may be candidates for active surveillance. Higher PSA density and higher proportion of cancer tissue with Gleason pattern 4 on biopsy are indications for treatment with curative intent.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S25.

UP-01.09: Canadian consensus guidelines for sexual rehabilitation following prostate cancer treatment

Dean S Elterman ¹, Anika Petrella ¹, Brandon Van Asseldonk ¹, Leah Jamnicky ¹, Gerald B Brock ², Stacy Elliott ³, Antonio Finelli ¹, Jerzy B Gajewski ⁴, Keith A Jarvi ⁵, John Robinson ⁶, Janet Ellis ⁷, Lauren Walker ⁸, Ashley Curtis ¹, Andrew Matthew ^1,⁹

Abstract

Introduction and Objectives:

Treatment options for prostate cancer (PCa) vary widely and depend on a number of factors. The prevalence of erectile dysfunction (ED) following radical prostatectomy (RP) is high (40–75%), and severely impacts patients’ sexual function and quality of life. The present descriptive analysis carried out by a pan-Canadian panel of medical experts summarizes best practices for PCa survivorship, with an overall aim of using these results to establish an online sexual health and rehabilitation clinic (SHARe-c), where patients can independently access medical guidance and care.

Methods:

Men’s health experts convened for the True NTH Sexual Health and Rehabilitation Initiative Consensus Meeting to address concerns about ED therapy and management following treatment for PC. The day-long meeting brought together experts from across Canada for discussion of current practices, latest literature, and patient interviews.

Results:

A baseline algorithm is presented in Fig. 1, incorporating surgical RP and degree of nerve-sparing or radiation-based therapy, and level of invasiveness. This algorithm provides an initial treatment approach from both a biomedical and psychosocial focus that can be more specifically tailored to different patient groups. Regular sexual activity is recommended, and there is further consideration for partner sexual dysfunction, libido concerns, climacturia, and dysorgasmia. Primary goals of long-term penile health, short-term erectile function, and psychosocial aspects are addressed with specific therapies at key milestones.

Conclusions:

With ED affecting such a large portion of men post-PC therapy, establishing best practices for sexual rehabilitation is critical. The guidelines proposed by the expert consensus have taken into account important factors, such as patient input, type of treatment, and timeline post-therapy, with the goal of becoming a nationwide standard and independently accessible online as SHARe-c.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S25.

UP-01.10: Open vs. extraperitoneal laparoscopic radical prostatectomy: Perioperative and oncologic outcomes for localized prostate cancer

Djuimo Yowou, Suzy Melody ¹, Simon Ouellet ¹, Marie-Catherine Charest-Bosse ², Robert Sabbagh ¹, Claudio Jeldres ¹

Abstract

Introduction and Objectives:

Laparoscopic and robot-assisted laparoscopic radical prostatectomies have showed some advantages as minimally invasive surgeries for cancer patients. Open radical prostatectomy (ORP) remains the gold standard of the surgical treatment of localized prostate cancer. Extraperitoneal laparoscopic radical prostatectomy (ELRP) more closely mimics the open approach than intraperitoneal or the robotic-assisted laparoscopy. Few studies have been reported on this technique. We wanted to compare perioperativeand oncologic outcomes of ELRP to open ORP in a single, tertiary Canadian centre from July 2006 to June 2010.

Methods:

A total of 442 patients were identified; 191 underwent ORP and 251 ELRP from July 2006 to June 2010 for a localized prostate cancer. Demographic, surgical, and pathologic data were collected for both groups. Student, Chi-square, Fisher, and Mann-Whitney tests were used for statistic analysis. Multivariate analysis with logistic regression was performed to evaluate the association of the surgical technique with the rate of complications and oncological results.

Results:

Some characteristics differ between the two groups at baseline; in the ORP group, patients were younger (62.7 vs. 64.2 years; p=0.007) and had lower-stage tumours (pT2, 73.3 vs. 62.2%; p=0.037). Operative time was shorter for ORP (148 vs. 173 minutes; p<0.001) from 2006 to 2009, but similar (149 vs. 153 minutes; p=0.377) after 2009. For ORP vs. ELRP, respectively, blood loss was 597 vs. 432 mL (p<0.001), postoperative stay was 3.2 vs. 2.9 days (p 0.133), lymph nodes count was 7 vs. 4.4 (p<0.001), and biochemical recurrence was 43.5 vs. 32.1% (p=0.018). There was no difference between the groups with regard to positive surgical margins (43.5 vs. 43.9%; p=0.995), complication rate (16.8 vs. 23.1%; p=0.100), or delay of recurrence (66.5 vs. 71 months; p=0.060). In multivariate analysis, surgical technique was not associated with an increased risk of complications (p=0.133) or biochemical recurrence (p=0.075).

Conclusions:

ELRP results in a significantly shorter length of hospital stay and lower blood loss than ORP. ORP seems to be faster, but the ELRP operative time is getting shorter with the learning curve. Also the lymph node count is higher with the ORP approach. In multivariate analysis, surgical technique was not associated with a higher risk of complications or biochemical recurrence.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S25–S26.

UP-01.11: The cost-effectiveness of Greenlight laser compared to transurethral resection of the prostate for patients with benign prostate hypertrophy

Dean S Elterman ¹, Ashley Curtis ¹

Abstract

Introduction and Objectives:

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate that affects up to 50% of men 50 years of age and older, and frequently leads to bothersome lower urinary tract symptoms (LUTS). Transurethral resection of the prostate (TURP) is the leading intervention used to ablate prostate tissue and restore normal urinary function. A newer, energy-based alternative called the Greenlight laser photoselective vaporization of the prostate (PVP) is less invasive, has a shorter surgical procedure, faster symptom improvement, and decreased morbidity compared to TURP.¹ The present study compares case costs and complication rates of both methods.

Methods:

We employed a single-centre descriptive analysis of average case cost summaries of BPH surgical procedures PVP and TURP (both traditional and with Olympus power button; OP) over a 19-month timeframe (2013–2015). Proportion of total cases, total cost (surgical cost + hospital stay), and proportions of post-treatment complications were calculated.

Results:

There were 147 BPH surgical cases. PVP, TURP, and TURP with OP accounted for 29%, 62%, and 10% of cases, respectively. Notably, only 10% of PVP surgeries required in-patient hospital stays, whereas nearly all TURP cases were hospitalized. When cost of surgical procedure and hospital stay were calculated, PVP offered total cost savings over TURP and TURP OP of 30.2% and 33.4%, respectively. Furthermore, readmission rates within 60 days were 0% for PVP patients and 14% for TURP (due to mechanical or medical complications).

Conclusions:

The newer, energy-based PVP is a minimally invasive treatment intervention for BPH, requiring shorter surgical case duration over traditional TURP. We found that PVP offered savings of approximately 31% over TURP and resulted in fewer complications that led to readmission. Considering its cost-effectiveness and medical benefits, PVP should be a leading treatment option for BPH-related LUTS.

References

1.Bowen JM, Whelan JP, Hopkins RB, et al. Photoselective vaporization for the treatment of benign prostatic hyperplasia. Ont Health Technol Assess Ser. 2013;13:1–34. [PMC free article] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S26–S27.

UP-01.12: Subjective intraoperative difficulty encountered by the surgeon at the time of robotic-assisted radical prostatectomy predicts continence recovery: Novel finding emphasizing role of the surgeon

Emad S Rajih ^1,², Malek Meskawi ¹, Abdullah M Alenizi ¹, Marc Zanaty ¹, Mansour Alnazari ¹, Kevin C Zorn ¹, Assaad El-Hakim ¹

Abstract

Introduction and Objectives:

It has been increasingly recognized that the surgeon plays an important role in functional and oncological outcomes post-robotic-assisted radical prostatectomy (RARP). In the current study, we examined the surgeon’s perception of difficulty encountered during surgery and its impact on continence recovery after RARP.

Methods:

We analyzed continence data of 322 patients with prostate cancer who underwent RARP between October 2006 and May 2015, operated by single surgeon (AEH), from a prospectively collected database. During surgery, the surgeon assessed several subjective parameters in an objective fashion using a Likert-type scale. These included overall difficulty (high-intermediate-low), quality of the anastomosis (perfect-good-poor), and overall satisfaction (high-intermediate-low). All patients were interviewed at one, three, six, 12, and 24 months after surgery. Primary endpoint was time to 0 pad usage per day. We presented the relative risks with 95% confidence intervals and we analyzed risk factors in univariate and multivariate cox regression analysis.

Results:

Overall difficulty encountered by surgeon at time of procedure predicted delayed continence recovery in multivariate analysis (HR of intermediate scale 0.63, 95% CI 0.45 0.87; p=0.006 and HR of low scale 0.52 95% CI 0.37–0.73; p=<0.001). However, surgeon impression on quality of anastomosis and surgeon overall satisfaction did not predict continence recovery. Prostate size (HR 0.71, 95% CI 0.5–0.99; p=0.04), and operative time (HR 0.99, 95% CI 0.98–0.99; p=0.02) were also independent predictors of delayed continence recovery. In our cohort, continence rates were 39%, 58%, 71%, 80%, and 91% at at one, three, six, 12, and 24 months, respectively. Moreover, preoperative high International Prostate Symptom Score (IPSS) index was associated with delayed continence recovery during the first year after surgery at all time intervals (p≤0.05). In addition, preoperative low Sexual Health Inventory for Men (SHIM) score predicted delayed continence recovery at 24 months (p≤0.05). No statistically significant correlation was found between body mass index, Charlson comorbidity index, or preoperative oncological parameters and continence recovery.

Conclusions:

Overall, difficulty encountered by surgeon at time of RARP is an independent predictor of continence recovery in addition to prostate size and preoperative IPSS. To our knowledge, this is the first time a subjective intraoperative parameter has been correlated with functional outcome post-RARP.

Table 1.

UP-01.12. Univariate and multivariate analysis, Cox regression analysis, of various factors in relation to postoperative early continence recovery

		Univariate		Multivariate

		HR (95% CI)	p value	HR (95% CI)	p value
Age		0.98 (0.96–1)	0.06	0.98 (0.96–1.01)	0.28
CCI
BMI	0–2	Reference	0.5	Reference	0.2
	≤25	Reference		Reference
	>25–30	0.95 (0.68–1.32)	0.8	1.02 (0.72–1.430	0.9
	>30	0.88 (0.61–1.27)	0.5	1.01 (0.68–1.51)	1
	unknown	0.76 (0.51–1.13)	0.2	0.79 (0.52–1.21)	0.3
PSA		0.99 (0.96–1.02)	0.6	0.99 (0.96–1.02)	0.5
Prostate size		0.99 (0.98–0.99)	0.002^*	0.99 (0.98–0.99)	0.05^*
Pathological stage
	T2a–b	Reference		Reference
	T2c	1.05 (0.78–1.41)	0.7	0.99 (0.73–1.35)	1
	T3a	0.84 (0.58–1.24)	0.4	0.87 (0.57–1.33)	0.5
	T3b–T4	1.3 (0.76–2.23)	0.3	1.41 (0.59–2.22)	0.7
Gleason score
	6	Reference		Reference
	3+4	0.81 (0.58–1.13)	0.2	0.81 (0.57–1.16)	0.3
	4+3	0.9 (0.55–1.49)	0.7	0.96 (0.55–1.68)	0.9
	≥8	0.93 (0.6–1.44)	0.7	0.91 (0.52–1.59)	0.8
Operative time		1 (1–1.01)	0.2	1.001 (1.001–1.01)	0.02^*
IPSS
	Mild	Reference		Reference
	Moderate	0.72 (0.56–0.94)	0.01^*	0.74 (0.56–0.98)	0.04^*
	Severe	0.57 (0.34–0.97)	0.04^*	0.57 (0.32–1.02)	0.06
SHIM
	No ED	Reference		Reference
	Mild	0.87 (0.65–1.16)	0.3	1 (0.74–1.36)	1
	Mild-Moderate	0.85 (0.57–1.25)	0.4	1.16 (0.75–1.79)	0.5
	Moderate	0.79 (0.42–1.46)	0.4	0.84 (0.43–1.66)	0.6
	Severe	0.64 (0.43–0.95)	0.03^*	0.78 (0.51–1.18)	0.2
Overall difficulty
	Low	Reference		Reference
	Intermediate	0.62 (0.46–0.84)	0.002^*	0.63 (0.45–0.87)	0.006^*
	High	0.51 (0.39–0.68)	<0.001^*	0.52 (0.37–0.73)	<0.001^*
Overall satisfaction
	High	Reference		Reference
	Intermediate	0.97 (0.5–1.88)	0.9	1.74 (0.82–3.7)	0.1
	Low	1.79 (0.74–4.33)	0.2	2.34 (0.89–6.16)	0.09

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BMI: body mass index; CCI: Charlson comorbidity index; CI: confidence interval; ED: erectile dysfunction; HR: hazard ratio; IPSS: International Prostate Symptoms Index; PSA: prostate-specific antigen; SHIM: Sexual Health Inventory for Men;

^*

statistically significant (p<0.05)

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S26–S28.

UP-01.13: An update on methods of assessment in robotic surgery: A urology perspective

Mitchell G Goldenberg ^1,², Jason Y Lee ^1,², Teodor Grantcharov ²

Abstract

Introduction and Objectives:

In recent years, there has been a rapid accumulation of new tools for assessment of robotic surgical skill, both technical and non-technical domains. The current climate in surgical assessment and accreditation calls for robust measurement of surgical skill, as the literature points to its impact on patient outcomes. Our objective in this article is to review the recent literature on robotic skills assessment and interpret the evidence from a urology viewpoint.

Methods:

A literature search of the MEDLINE, PsycINFO, and Embase databases was performed for publications from January 2010 to January 2016 on technical and non-technical skills assessment in robotic surgery.

Results:

The search yielded 124 papers; abstracts were reviewed. The search included articles not directly related to urology, and so here we focus on those papers pertaining more to urologic surgery. Table 1 shows those tools identified in our search that have been used in, or developed for, robotic surgery technical and non-technical skills assessment.

Conclusions:

There has been a rapid expansion in robotic surgical skills assessment, both in simulated and real operating room settings. Global rating scales have become the predominant rubric for technical skills assessment, but procedure-specific checklists also demonstrate concurrent and external validity. To date, non-technical skills have been assessed with instruments that are not specific to robotic surgery. Crowdsourcing has emerged as another novel method of formative assessment providing rapid and validated feedback to trainees and has the potential to be used in summative assessment and credentialing practices as well.

Table 1.

UP-01.13.

Technical skills
Assessment tool	Type of xcale	Measured domains	Internal consistency	Concurrent validity	Construct validity
GEARS	GRS	Depth perception Bimanual dexterity Efficiency Force sensitivity Autonomy Robotic control	Very high	Moderate	Yes
R-OSATS	GRS	Depth perception/accuracy Force/tissue-handling Dexterity Efficiency	High	Unknown	Yes
RACE	Checklist	Needle-positioning Needle entry Needle-driving and tissue trauma Suture placement Tissue-approximation Knot-tying	Moderate	Moderate	Yes
OSATS	GRS	Respect for tissue Time and motion Instrument handling Knowledge of instruments Use of assistants Flow of operation & forward-planning Knowledge of specific procedure	Moderate to high	High	Yes
GOALS+	GRS	Depth perception Bimanual dexterity Efficiency Tissue-handling Participant autonomy Instrument awareness and precision Camera awareness and precision	Unknown	High	Yes
Contact Vibration	Unique metric	Instrument vibration and force of movement (via accelerometers)	High to very high	High	Yes
Non-technical skills
Assessment tool	Scale		Measured domains		Use in robotic surgery
NOTSS	N/A = Not applicable skill 1 = Poor 2 = Marginal 3 = Acceptable 4 = Good		Situation awareness Decision-making Communication and teamwork Leadership Leadership and management		Volpe et al.
NOTECHS	1 = Below standard 2 = Basic standard 3 = Standard 4 = Excellent		Teamwork and cooperation Problem-solving and decision-making Situational awareness		Patki et al.
OTAS	Rating anchors 0 = Problematic behaviour 1 = Team function 2 = Slight detriment to team function 3 = Team tunction neither hindered nor enhanced 4 = Behaviour enhances team function 5 = Behaviour greatly enhances team function 6 = Exemplary behaviour		Communication Coordination Cooperation and backup behaviour Leadership Team-monitoring and situational awareness		Randall et al.

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S29–S30.

UP-01.14: Androgen-deprivation therapy is not associated with depression: Results of a two-year prospective cohort study

Steven Tong ¹, Dean R Tripp ^1,², Hayley D Yurgan ², Laura Katz ², Adriana Koliuskov ³, Angela Black ¹, Stephanie Hughes ³, D Robert Siemens ¹

Abstract

Introduction and Objectives:

The presence, timing, and magnitude of effect of androgen-deprivation therapy (ADT) on anxiety and depression are controversial in prostate cancer (PCa). This is an analysis of a two-year prospective cohort study investigating the influence of ADT on patient depression and quality of life (QoL).

Methods:

Three cohorts of men with PCa were enrolled: a control group consisting of patients on watchful waiting (Group A), those initiating ADT for advanced disease (Group B), and those undergoing adjuvant ADT in a combined-modality curative protocol for higher-risk cancer (Group C). Patients were assessed every three months from baseline for two years. Questionnaire data were collected to assess depression and QoL.

Results:

There were no significant group differences at baseline in terms of age (p=0.57), marital status (p=0.80), depression (p=0.32), or mental QoL (p=0.11). A repeated measures ANOVA examined differences in mental QoL, physical QoL, and depression from the baseline assessment up to two years. A significant main effect was found for time (p =0.01) on mental QoL, but not for group (p=0.32). Additionally, there was a significant decrease in mental composite scores over time in Group C (p=.01). Results show a significant main effect of treatment group (p=0.02) on physical QoL, but no main effect of time (p=0.70). Group A (M=41.14, SE=2.25) reported significantly lower physical QoL scores than Group C (M=49.10, SE=1.84). Interestingly, there were no significant main effects for time (p=0.07), group (p=0.23), or the interaction (p=0.65) on depression.

Conclusions:

Individuals receiving any form of treatment ADT had significant decrease in mental QoL over time in comparison to controls. Further, individuals in receiving ADT were more likely to experience reductions in their physical QoL compared to controls. All individuals within this sample appeared to have an increase in depressive symptoms over time, however, the decrease was not statistically significant.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S29.

UP-01.15: Characterizing APCaRI participants by their patient-reported outcomes

Ian TS Wright ¹, Trafford Crump ¹, Richard J Baverstock ¹

Abstract

Introduction and Objectives:

Patient-reported outcomes (PROs) are validated questionnaires intended to measure patients’ functional status and symptom severity. By including PROs as part of the routine collection of data in a clinical registry, they can be used to characterize sub-groups of patients and track changes in their symptoms over time. The purpose of this presentation is threefold, to: 1) report on the PROs being collected in the APCaRI registry; 2) describe the APCaRI sample using the PROs collected at intake; and 3) provide an example of how PROs can be used to characterize a sub-group of patients with suspected overactive bladder (OAB).

Methods:

The APCaRI clinical registry includes generic and condition-specific PROs, including: EQ-5D, Expanded Prostate Cancer Index Composite (EPIC)-26, and the International Prostate Symptom Score (IPSS). Data from the APCaRI clinical registry was extracted and de-identified for analysis. Responses to the EQ-5D were analyzed for its five items: mobility, self-care, usual activities, pain/discomfort, depression/anxiety. Responses to the EPIC-SF were analyzed for its five domains: urinary incontinence, urinary irritative/obstructive, bowel, sexual, and hormonal. Responses to the IPSS were analyzed for its global score. Relevant items were extracted from the PROs to characterize those patients with suspected OAB.

Results:

Complete PRO data collected at intake were available for 657 (83%) of 794 patients in the APCaRI registry. The results are summarized in Table 1.

162 patients met our criteria for OAB at intake. Zero (0) PROs were available for 276 patients at six-month followup, and for 28 (24%) out of 115 patients at 12-month followup.

Conclusions:

PROs can be used by APCaRI investigators to supplement their characterization of patients’ prostate cancer-related symptoms and the impact these have on their quality of life. Collection of PROs at followup should be emphasized in order to track these outcomes over time.

Table 1.

UP-01.15.

EQ-5D (# patients reporting moderate or severe)	(n=664)

Mobility	31
Self care	7
Usual activities	7
Pain/discomfort	10
Depression/anxiety	6

EPIC-26 (median values out of 100)

Urinary incontinence	83.75
Urinary irritative/obstructive	93.75
Bowel	100.00
Sexual	52.83
Hormonal	100.00

IPSS (median value of out 35)

Global score	6.0

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S29–S30.

UP-01.16: Concomitant use of emerging therapies and bone-targeting agents in prostate cancer: Observations from real-world data

Antonio Finelli ¹, Rohini K Hernandez ², Jan Lethen ², Sally Wade ³, Douglas Warner ², Amy P Abernethy ⁴, Alexander Liede ²

Abstract

Introduction and Objectives:

Clinical guidelines recommend emerging therapies and bone-targeting agents (BTAs) to treat castration-resistant prostate cancer (PCa) patients with evidence of bone metastases. However, real-world use of new therapies and BTAs is not well understood.

Methods:

Electronic medical records (Flatiron Health; >1 million patients; 220 US cancer clinics) were used to identify men ≥18 years with PCa (ICD-9 185/ICD 10 C61) with ≥1 emerging therapy (abiraterone acetate, cabazitaxel, enzalutamide, radium 223, sipuleucel-T) in 2014, with or without BTA (denosumab or zoledronic acid).

Results:

3890 PCa patients (mean age 74.4 years) received an emerging therapy in 2014: abiraterone (57%), enzalutamide (48%), cabazitaxel (11%), sipuleucel-T (8%), and radium 223 (5%) (nonexclusive categories). In 2014, 68% received chemotherapy (82% ever), 18% docetaxel (39% ever), and 54% androgen-deprivation therapy (60% ever). Among new users, abiraterone (54%), enzalutamide (30%), and sipuleucel-T (11%) were most common in the pre-docetaxel setting (n=1745). In the post-docetaxel setting (n=282), enzalutamide (35%), abiraterone (31%), and cabazitaxel (27%) were most common. Among BTA users (n=2422; 62%) (Table 1), more patients received denosumab (73%) than zoledronic acid (38%). In 2014, patients averaged 3.5 (standard deviation (SD) 2.9) administrations of emerging therapies and 6.9 (SD 3.9) of BTAs.

Conclusions:

Real-world data from oncology practices across the US suggest that abiraterone and enzalutamide are the novel agents of choice in PCa, with abiraterone preferred overall, pre-docetaxel, and with BTAs. Urologic oncologists are comfortable coadministering emerging therapies and BTAs where almost two-thirds of patients received a BTA in 2014. Future research can address optimal sequence or combination of emerging therapies and impact on patient outcomes.

Table 1.

UP-01.16

	Any BTA N (%)	Denosumab N (%)	Zoledronic acid N (%)
Any ermerging therapy	2422	1776	920
Same day	1328 (55)	905 (51)	451 (49)
Within two weeks	2233 (92)	1535 (86)	757 (82)
Abiraterone acetate	1372 (57)	1008 (57)	510 (55)
Cabazitaxel	318 (13)	197 (11)	162 (18)
Enzalutamide	1184 (49)	884 (50)	425 (46)
Radium 223	153 (6)	119 (7)	56 (6)
Sipuleucel-T	223 (9)	168 (9)	76 (8)

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S30–S31.

UP-01.17: Smoking is an independent risk factor of continence recovery after robotic-assisted radical prostatectomy: Long-term results from a prospective Canadian cohort

Emad S Rajih ^1,², Malek Meskawi ¹, Abdullah M Alenizi ¹, Marc Zanaty ¹, Mansour Alnazari ¹, Naif Alhathal ¹, Kevin C Zorn ¹, Assaad El-Hakim ¹

Abstract

Introduction and Objectives:

Delayed continence recovery is the most bothersome complication post-prostatectomy. Several studies have reported the effect of various preoperative and intraoperative parameters on continence recovery. The role of active smoking has not been well studied.

Methods:

We analyzed continence data of 322 patients with prostate cancer who underwent robot-assisted radical prostatectomy (RARP) between October 2006 and May 2015 by single surgeon (AEH). All patients were interviewed at one, three, six, 12, and 24 months after surgery. We analyzed the risk factors for urinary incontinence from prospectively collected database in univariate and multivariate cox regression analysis. Primary endpoint was time to 0 pad usage per day.

Results:

Smoking at time of surgery predicted delayed continence recovery in multivariate analysis (HR 0.71, 95% CI 0.5–0.99; p=0.04). Furthermore, bladder neck-sparing (HR 0.71, 95% CI 0.5–0.99; p=0.04), prostate size (HR 0.99; 95% CI 0.98–0.99; p=0.02), and operative time (HR 1.001, 95% CI 1.001–1.01; p=0.03) were independent predictors of continence recovery after RARP. In our cohort, 0 pad continence rates were 39%, 58%, 71%, 80%, and 91% at one, three, six, 12, and 24 months, respectively. Age and neurovascular bundle preservation were associated with continence recovery only in univariate analysis. No statistically significant correlation was found with other variables, such as body mass index, Charlson comorbidity index, preoperative oncological factors, presence of median lobe, or thermal use.

Conclusions:

Our results suggest that smoking at the time of surgery is a major factor responsible for delayed continence recovery. Men with large prostate glands, non-bladder neck-sparing, and longer operative times should be counselled on the increased risk of urinary incontinence postoperatively. The association between smoking and postoperative incontinence has not been well-documented until now. These results need to be validated by others.

Table 1.

UP-01.17. Univariate and multivariate analysis, Cox regression analysis of various factors in relation to postoperative early continence recovery

	Univariate		Multivariate

	HR (95% CI)	p value	HR (95% CI)	p value

Age	0.98 (0.96–1)	0.06	0.99 (0.96–1.02)	0.3
CCI
0–2	Reference	0.5	Reference	0.5
>3	0.92 (0.72–1.17)		1.12 (0.79–1.59)
BMI
≤25	Reference		Reference
>25–30	0.95 (0.68–1.32)	0.8	0.99 (0.7–1.39)	0.9
>30	0.88 (0.61–1.27)	0.5	0.83 (0.56–1.22)	0.3
unknown	0.76 (0.51–1.13)	0.2	0.85 (0.56–1.28)	0.4
PSA	0.99 (0.96–1.02)	0.6	0.99 (0.96–1.02)	0.5
Prostate size	0.99 (0.98–0.99)	0.002^*	0.99 (0.98–0.99)	0.02^*
Pathological stage
T2a–b	Reference		Reference
T2c	1.05 (0.78–1.41)	0.7	1.06 (0.78–1.43)	0.7
T3a	0.84 (0.58–1.24)	0.4	0.93 (0.61–1.41)	0.7
T3b–T4	1.3 (0.76–2.23)	0.3	1.41 (0.73–2.72)	0.3
Gleason score
6	Reference		Reference
3+4	0.81 (0.58–1.1 3)	0.2	0.82 (0.58–1.17)	0.3
4+3	0.9 (0.55–1.49)	0.7	0.83 (0.48–1.46)	0.5
≥8	0.93 (0.6–1.44)	0.7	0.96 (0.55–1.67)	0.9
Operative time	1 (1–1.01)	0.2	1.001 (1.001–1.01)	0.03^*
Smoking history
No	Reference	0.06	Reference	0.04^*
Yes	0 .73 (0.53–1.01)		0.71 (0.5–0.99)
Median lobe
No	Reference	0.9	Reference	0.4
Yes	0.98 (0.7–1.37)		1.18 (0.82–1.69)
Use of perineal pressure
No	Reference	0.6	Reference	0.7
Yes	0.87 (0.56–1.36)		1.1 (0.68–1. 77)
Thermal use
No	Reference	0.6	Reference	0.5
Yes	0 .94 (0.72–1.22)		0.9 (0.69–1.19)
BN sparing
No	Reference	0.02^*	Reference	0.04^*
Yes	1.41 (1.06–1.88)		1.41 (1.01–1.96)
NVB preservation
No	Reference		Reference
Unilateral	1.55 (1.01–2.4)	0.04^*	1.53 (0.96–2.44)	0.08
Bilateral	1.5 (1.01–2.23)	0.04^*	1.41 (0.91–2.2)	0.1

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BMI: body mass index; BN: bladder neck; CCI: comorbidity index; CI: confidence interval; HR: hazard ratio; NVB: neurovascular bundles; PSA: prostate-specific antigen;

^*

statistically significant (p<0.05).

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S30, S32-S33.

UP-01.18: Continence recover after vesicourethral anastomosis with bidirectional barbed polyglyconate (V-Loc 180^®) vs. polyglecaprone (Monocryl^®) suture in robotic-assisted radical prostatectomy

Emad S Rajih ^1,², Malek Meskawi ¹, Abdullah M Alenizi ¹, Marc Zanaty ¹, Mansour Alnazari ¹, Naif Alhathal ¹, Kevin C Zorn ¹, Assaad El-Hakim ¹

Abstract

Introduction and Objectives:

To evaluate long-term functional outcome with time to 0 pad after vesicourethral anastomosis (VUA) using mono-filament poliglecaprone versus barbed polyglyconate suture in robotic-assisted radical prostatectomy (RARP).

Methods:

From October 2006 to May 2015, 322 patients who underwent RARP in a single centre by same surgeon (AEH) included in a prospectively collected database were analyzed in a retrospective study. All patient underwent continuous, single-layer running anastomosis during RARP with either monofilament suture (n=141) or barbed suture (n=181). Primary outcome measures were time to 0 pad at one, thee, six, 12, and 24 months followup. Secondary outcomes were anastomosis time and perioperative complications.

Results:

Continence rates were different between both groups up to one year, favouring monofilament suture. 0 pad continence rates in mono-filament group and barbed suture group at one, thee, six, 12 and 24 months were 56% vs. 26% (p<0.001), 73% vs. 36.4% (p<0.001), 84.4% vs. 60.2% (p<0.001), 90.8% vs. 71.9% (p<0.001), and 93.5% vs.87.1% (p=0.1), respectively. Anastomosis time was shorter in V-Loc group with a mean of 24.5 min vs. 31.6 min (p<0.001). Independent predictors of continence were suture type (HR 0.53, 95% CI 0.41–0.68; p=0.02) and smaller prostate size (HR 0.99, 95% CI 0.98–0.99; p<0.001) in a multivariate Cox logistic regression analysis.

Conclusions:

VUA with barbed suture might contribute to delayed continence recovery in the first year following RARP. This provocative finding is hypothesis-generating and should be tested in a prospective randomized study.

Table 1.

UP-01.18. Patient characteristics

Variables	Monofilament (Monocryl^®) n=141	Barbed (V-Loc 180^®) n=181	p value

	Mean (IQR) or number of patients (%)
Age (years)	60.6 (61)	61 (61)	0.7
BMI
≤25	26 (18.4%)	36 (19.9%)
>25–30	70 (49.6%)	64 (35.4%)	0.04
>30	28 (19.9%)	42 (23.2%)
Unknown	17 (12.1%)	39 (21.5%)
PSA (ng/ml)	6.5 (5.2)	7.1 (6)	0.002
Prostate volume (g)	46 (42.5)	52.3 (50)	<0.001
Pathological stage
T2a–b	21 (14.9%)	52 (28.7%)
T2c	87 (61.7%)	82 (45.3%)	0.01
T3a	25 (17.7%)	36 (19.9%)
T3b–T4	8 (5.7%)	11 (6.1%)
Gleason score
6	26 (18.4%)	24 (13.3%)
3+4	90 (63.8%)	111 (61.3%)	0.1
4+3	13 (9.2%)	15 (8.3%)
≥8	12 (8.5%)	31 (17.1%)
Anastomosis time (min)	31.6 (30)	24.5 (23)	<0.001
Blood loss (mI)	336 (300)	325 (300)	0.5
BN reconstruction
No	131 (92.9%)	173 (95.6%)	0.3
Yes	10 (7.1 %)	8 (4.4%)
NVB preservation
No	94 (66.7%)	105 (58%)	0.4
Partial	36 (25.5%)	57 (31.5%)	0.4
Complete	II (7.8%)	19 (10.5%)

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BMI: body mass index; BN: bladder-neck; IQR: interquartile range; NVB: neurovascular bundles; PSA: prostate-specific antigen.

Table 2.

UP-01.18. Univariate and multivariate analysis, Cox regression analysis, of various factors in relation to postoperative early continence recovery

	Univariate		Multivariate

	HR (95% CI)	p value	HR (95% CI)	p value

Age	0.98 (0.96–1)	0.06	0.99 (0.97–1.01)	0.5
BMI
≤25	Reference		Reference
>25–30	0.95 (0.68–1.32)	0.8	0.9 (0.65–1.26)	0.5
>30	0.88 (0.61–1.27)	0.5	0.88 (0.6–1.29)	0.5
unknown	0.76 (0.51–1.13)	0.2	0.82 (0.55–1.24)	0.4
PSA	0.99 (0.96–1.02)	0.6	1 (0.97–1.03)	0.9
Prostate size	0.99 (0.98–0.99)	0.002^*	0.99 (0.98–0.99)	0.02^*
Pathological stage
T2a–b	Reference		Reference
T2c	1.05 (0.78–1.41)	0.7	0.97 (0.72–1.31)	0.8
T3a	0.84 (0.58–1.24)	0.4	0.81 (0.54–1.23)	0.3
T3b–T4	1.3 (0.76–2.23)	0.3	0.97 (0.5–1.88)	0.9
Gleason score
6	Reference		Reference
3+4	0.81 (0.58–1.13)	0.2	0.79 (0.55–1.12)	0.2
4+3	0.9 (0.55–1.49)	0.7	0.93 (0.53–1.62)	0.8
≥8	0.93 (0.6–1.44)	0.7	1.18 (0.60–2.02)	0.6
EBL	1 (1–1)	0.6	1 (1–1)	0.5
BN reconstruction
No	Reference	0.7	Reference	0.9
Yes	0.91 (0.54–1.52)		0.71 (0.5–0.99)
Anastomotic suture
Monocryl^®	Reference	<0.001^*	Reference	<0.001^*
V-Loc 180^®	0.52 (0.41–0.66)		0.53 (0.4 1–0.68)
NVB preservation
No	Reference		Reference
Partial	0.98 (0.75–1.29)	0.9	1.13 (0.84–1.5)	0.4
Complete	0.71 (0.46–1.09)	0.1	0.79 (0.49–1.28)	0.3

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BMI: body mass index; BN: bladder neck; CI: confidence interval; HR: hazard ratio; NVB: neurovascular bundles; PSA: prostate-specific antigen;

^*

statistically significant (p<0.05).

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S31-S32, S34.

UP-01.19: New perioperative risk factors for biochemical recurrence after robotic-assisted radical prostatectomy: A single-surgeon experience in high-volume Canadian centre

Emad S Rajih ^1,², Malek Meskawi ¹, Abdullah M Alenizi ¹, Marc Zanaty ¹, Mansour Alnazari ¹, Naif Alhathal ¹, Kevin C Zorn ¹, Assaad El-Hakim ¹

Abstract

Introduction and Objectives:

To identify and assess new predictive factors for biochemical recurrence (BCR) in patients undergoing robotic-assisted radical prostatectomy (RARP) in a Canadian cohort.¹^–³

Methods:

After Institutional Board approval, a retrospective review of 326 patients who underwent RARP from October 2006 to May 2013 was accomplished. All cases were performed by a single surgeon (AEH) and data collected prospectively. Univariate and multivariate logistic regression analysis were performed. Variables analyzed include age, body mass index (BMI), year of surgery, statin use, oncological parameters, prostate volume, operative time, estimated blood loss, number of neurovascular bundles (NVB) preservation, NVB preservation time, apical dissection time, capsulotomy, and difficult pelvis anatomy (narrow and deep). BCR was defined as prostate-specific antigen (PSA) >0.2 ng/ml, patients who received adjuvant or salvage radiotherapy, and/or hormonal-deprivation therapy. We include in our study all patients who had at least a two-year followup.

Results:

53 (16.2%) out of 326 patients had BCR. 80 (9.2%) patients had positive surgical margin (PSM), of whom 51(63.7%) had no BCR and 29 (36.3%) had BCR. In univariate analysis, significant predictors of BCR included: year of surgery (p=0.01), PSA (p=0.003), PSA density (p=0.0001), pathological grade (p=0.0001), pathological stage (p=0.0001), PSM (0.0001), mean operative time (p=0.001), NVB release time (p=0.001), and apical dissection time (p=0.007). However, other covariates were not significant (p≥0.05). On multivariate analysis, PSM (p=0.0001), as well as year of surgery (p=0.01) and operative time (p=0.04) were significantly associated with BCR.

Conclusions:

PSM, prolonged operative time, and earlier year of surgery were independent predictors of BCR after RARP. These factors emphasize the role of surgeon experience in oncological outcomes post-RARP.

Table 1.

UP-01.19.

Covariates	No BCR n=273	+ve BCR n=53	p value	Multivariate analysis RR (CI 95%; p value)

	Mean (median) or number of patients (%)
Age (years)	60.8 (61)	60.1 (61)	0.65
BMI	28 (26.8)	28.1 (26.2)	0.97
Prostate size	49.5 (47)	48 (44)	0.17
PSA (ng/ml)	6.54 (5.5)	8.9 (6.9)	0.003	1.16 (9.9–1.4); 0.17
PSAD	0.14 (0.11)	0.2 (0.14)	0.006	0.008 (0–19.1); 0.17
Grade
6	46 (90.2%)	5 (9.8%)		Reference
3+4	183 (89.7%)	21 (10.3%)	0.0001	0.5 (0.16–1.8); 0.30
4+3	17 (60.7%)	11 (39.3%)		3.1 (0.72–13.48); 0.12
≥8	27 (62.8%)	16 (37.2%)		1.76 (0.35–8.71); 0.49
Pathological stage
T2a–b	65 (89%)	8 (11%)		Reference
T2c	151 (88.3%)	20 (11.7%)	0.0001	0.7 (0.25–2.34); 0.64
T3a	48 (76.2%)	15 (23.8%)		1.59 (0.44–5.67); 0.48
T3b–T4	9 (47.4%)	10 (52.6%)		1.15 (0.2–6.49); 0.87
Prop positive cores	3.9 (4)	4.4 (4)	0.17	0.96 (0.69–1.06); 0.78
Surgical margin
−ve SM	222 (90.2%)	24 (9.8%)	0.0001	Reference
+ve SM	51 (63.7%)	29 (36.3%)		5.1 (2.1–12.5); 0.0001^*
% biopsy tumour volume	34.3 (33.3)	40.1 (41.6)	0.06	1.01 (0.98–1.06); 0.38
Statin use
No	180 (90.2%)	36 (16.7%)	0.77	—
Yes	93 (84.5%)	17 (15.5%)

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Table 2.

UP-01.19.

Covariates	No BCR n=273	+ve BCR n=53	p value	Multivariate analysis RR (CI 95%; p value)

	Mean (median) or number of patients (%)
Year of surgery
2006–2010	118 (78.1%)	33 (21.9%)	0.01	1 (1.0–1.0); 0.01*
2011–2015	155 (88.6%)	20 (11.4%)
Operative time (min)	208.2 (200)	249 (226)	0.0001	1 (1–1.02); 0.04*
Blood loss (ml)	326 (300)	340 (300)	0.61	0.9 (0.98–1.0); 0.29
NVB release time (min)	43 (41)	52 (50)	0.001	—
Apical resection time (min)	10 (0.11)	14 (0.14)	0.006	0.9 (0.94–1.04); 0.71
NVB preservation
No	49 (80.3%)	12 (19.7%)	0.77	Reference
Unilateral	95 (84.1%)	18 (15.9%)		0.96 (0.3–3.09); 0.95
Bilateral	129 (84.9%)	23 (15.1%)		1.15 (0.35–3.76); 0.81
Compromised pelvis
No	219 (85.2%)	38 (14.8%)	0.16	—
Yes	54 (78.3%)	15 (21.7%)	0.16	—
Capulotomy
No	292 (84.2%)	38 (15.8%)	0.72	—
Yes	71 (82.6%)	15 (21.4%)	0.72	—
Overall difficulty
Easy	115 (87.1%)	17 (12.9%)	0.38	—
Mixed	71 (80.7%)	17 (19.3%)
Difficult	87 (82.1%)	19 (17.9%)

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References

1.Hashimoto T, Yoshioka K, Nagao G, et al. Prediction of biochemical recurrence after robot-assisted radical prostatectomy: Analysis of 784 Japanese patients. Int J Urol. 2015;22:188–93. doi: 10.1111/iju.12624. [DOI] [PubMed] [Google Scholar]
2.Tanimoto R, Fashola Y, Scotland KB, et al. Risk factors for biochemical recurrence after robotic assisted radical prostatectomy: A single surgeon experience. BMC Urol. 2015;15:27. doi: 10.1186/s12894-015-0024-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Hashimoto T, Yoshioka K, Gondo T, et al. Preoperative prognostic factors for biochemical recurrence after robot-assisted radical prostatectomy in Japan. Int J Clin Oncol. 2014;19:702–7. doi: 10.1007/s10147-013-0611-0. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S32.

UP-01.20: The effect of androgen-deprivation therapy on C-reactive protein levels in men with prostate cancer

Zeyu Li ¹, Angela Black ¹, Wilma Hopman ¹, D Robert Siemens ¹

Abstract

Introduction and Objectives:

The potential contribution of androgen-deprivation therapy (ADT) to cardiovascular mortality in men with prostate cancer is very controversial. C-reactive protein (CRP) has long been used as a marker for cardiovascular risk. The purpose of this study is to investigate the effects of ADT on CRP levels in patients with prostate cancer.

Methods:

This is a single-centre, prospective study where 44 men undergoing primary hormone therapy or adjuvant/neoadjuvant hormone therapy were recruited and followed with blood work at three-month intervals from initiation of hormone therapy for 24 months. A group of 19 men with prostate cancer under active surveillance were recruited as controls.

Results:

There were no differences in age and cardiovascular comorbidities between the ADT group and control group. The ADT group had significant higher Charlson Comorbidity Index when compared to the control group (p<0.001). 32 participants from the ADT group and 14 from the control group remained in the study at 12 months. 21 participants from the ADT group and 11 from the control group remained at 24 months. The ADT group had significantly higher CRP levels at 12 months when compared to controls (p=0.025). There were no significant differences in CRP levels between the groups from 15 to 24 months.

Conclusions:

There does appear to be elevation of CRP levels in patients with prostate cancer who are on ADT. Small sample sizes and loss to followup limited analysis beyond 12 months. Future studies with larger cohorts should be made to better understand effects of ADT on CRP levels.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S35.

MP-02.01: Cause and effect vs. confounding: Is there a true association between caudal blocks and tubularized incised plate repair complications?

Luis H Braga ¹, Kizanee Jegatheeswaran ¹, Mandy Rickard ¹, Bethany Easterbrook ¹, Melissa McGrath ¹, Armando J Lorenzo ², Jorge E DeMaria ¹

Abstract

Introduction and Objectives:

Recent evidence suggests that complications post-hypospadias repair are more likely in children who receive caudal blocks (CB), however, the validity of this association remains undetermined. Herein we compare the rate of urethrocutaneous fistula (UCF) and glans dehiscence (GD) in post-tubularized incised plate (TIP) repair patients who received a CB compared to those who had dorsal penile block (DPB).

Methods:

Between 2004 and 2015, 820 patients underwent hypospadias repair by two surgeons and were retrospectively reviewed. Re-do cases, non-TIP repairs, and incomplete medical records were excluded (n=302). Anesthesia type was anesthesiologist-dependent. Age at surgery, meatal location (ML), preoperative testosterone stimulation (PTS), type of regional anesthesia, degree of ventral curvature (VC), surgeon effect, and complications were captured. All cases had a two-layer PDS stented TIP urethroplasty covered by dartos flap. Uni and multivariable analyses of risk factors for complications were carried out. ML and VC were grouped as a single variable in the logistic regression model to account for the interaction between factors.

Results:

Median age at surgery and followup time were 18 and three months, respectively. Of 518 patients, 38 (7%) developed complications: 21 UCF (19 CB, 2 DPB) and 17 GD (14 CB, 3 DPB). On univariate analysis, PTS vs. no PTS (13.4% vs. 6.2%; p=0.03), midshaft/proximal vs. distal defects (15.9% vs .4.7%; p<0.01) and use of CB (8.5% vs 3.3%; p=0.03) were significantly associated with higher complication rates. However, the associations involving PTS (OR=1.3, 95% CI 0.4–3.9) and CB (OR=2.3; 95% CI 0.9–6.4) with complications did not hold during multivariable analysis, leaving ML/VC as the only independent risk factor for development of UCF/GD (OR=2.4, 95% CI 1.2–5.7; p=0.04).

Conclusions:

Hypospadias severity, and not type of anesthesia, is the main risk factor for UCF/GD. The previously reported association between CB and UCF/GD is likely due to confounding. To assess the real impact of CB on hypospadias complications a randomized, controlled trial is needed.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S35.

MP-02.02: Factors contributing to delay in time to orchidopexy in Ontario, Canada

Siobhan Telfer ^1,², Kuan Liu ³, Salimah Z Shariff ³, Amit X Garg ⁴, Sumit Dave ^1,²

Abstract

Introduction and Objectives:

The 2015 AUA guideline on cryptorchidism recommends early referral to a surgeon to ensure orchidopexy by 18 months of age. In a prior study, we noted that median time to orchidopexy in Ontario was 23 months (interquartile range (IQR) 16–34). The objective of this study was to identify factors contributing to this delay in orchidopexy.

Methods:

We conducted a population-based, retrospective, cohort study using several linked administrative databases held at the Institute for Clinical Evaluative Sciences in Ontario. We identified 4399 patients who underwent orchidopexy between 2006 and 2011 and assessed several patient (socioeconomic status, healthcare visits, and surrogate markers of concern, such as hypospadias, preoperative ultrasound, bilateral or impalpable undescended testes (UDT), treating and referring physician (age and specialty), and hospital factors (volume and academic/community) that could impact timing of surgery. Multivariable logistic regression analyses were performed to compare boys who had orchidopexy before 18 months of age or after.

Results:

The median age at surgery was 24 months (IQR 12–60). Patients who had an orchidectomy during exploration (OR1.61, CI 1.22–2.13), underwent laparoscopic orchidopexy (OR 1.57, CI 1.13–2.17), were operated by pediatric general surgeons versus urologists (OR1.69, CI 1.40–2.03), and at high-volume hospitals (OR 1.79, CI 1.38–2.33) had a greater likelihood of surgery beyond 18 months. Patients with more healthcare encounters (OR 0.94, CI 0.92–0.95), with prior ICU hospitalizations (OR 0.29, CI 0.15–0.58), hypospadias (OR 0.81, CI 0.58-1-12), or bilateral UDT (p<0.001) (OR 0.72, CI 0.58–0.89) were more likely to undergo timely surgery. In 3969 patients, (where first surgical clinic visit was documented), age at consult was 20 months (IQR 10–60). Counterintuitively, when there was a delay to the first consult, the eventual surgical procedure was likely to be done earlier (OR 0.84, CI 0.83–0.85).

Conclusions:

In Ontario, time to orchidopexy far exceeds current recommendations, as 75% of patients with UDT have not had surgery by 18 months. In this study, we identified several patient, physician, and hospital factors contributing to this delay. Despite guideline recommendations, late first surgeon assessment still seems to be the main barrier to timely surgical intervention.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S35–S36.

MP-02.03: Younger patient age and bulbar strictures are associated with improvement in ejaculatory function after urethroplasty: Results of a prospective analysis

Trevor Haines ¹, Keith F Rourke ¹

Abstract

Introduction and Objectives:

In addition to voiding dysfunction, urethral strictures may cause ejaculatory dysfunction. However, urethroplasty (UP) involves dissection near structures that are responsible for normal ejaculation. We aim to prospectively assess the changes and determinants of ejaculatory function (EjF) following UP.

Methods:

Patients undergoing UP since Feb 2011 were offered enrollment in a prospective study examining changes in sexual function post-urethroplasty. Patients completed the IIEF questionnaire pre-operatively and at approximately six months. IIEF q9–10 scores were analyzed pre- and post-UP and compared with patient and operative factors, including stricture length, location, urethral transection, and age. Overall mean change in EjF pre- to post-operatively was calculated with Wilcoxon non-parametric tests. The change in EjF and its relationship to operative and patient factors was assessed with Chi-square and logistic regression.

Results:

A total of 104 patients were analyzed. Mean patient age was 47 years and mean stricture length was 3.8 cm. Preoperative EjF scores (6.09), and postoperative EjF scores (6.52) were unchanged (p=0.24). 53.8% of patients experienced no change in their EjF score. 20.2% of patients experienced a decrease of one or more points, while 26% experienced an improvement of one or more points. When comparing bulbar to penile strictures, there was a significant difference in mean change in EjF (p=0.03). Bulbar strictures were more likely to have an improvement in EjF scores following UP (30.8% vs. 11.5%; p=0.05). Younger patient age, both when assessed as a categorical (>50 years) and continuous variable (p=0.001) was associated with improvement in EjF postoperatively (35.4%vs. 14.6%; p=0.01). Urethral transection (p=0.86) and stricture length (p=0.56) had no impact on EjF.

Conclusions:

For the majority of patients, EjF is not affected by UP. However, younger patients, as well as patients with bulbar stricture, are more likely to notice an improvement in their EjF following UP.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S36.

MP-02.04: Predictors of stricture recurrence after bulbar urethroplasty: Multivariate analysis of 596 bulbar urethroplasties

Keith F Rourke ¹, David Chapman ¹

Abstract

Introduction and Objectives:

Bulbar urethral strictures are the most common form of urethral stricture. Although urethroplasty (UP) is the most effective treatment, some patients develop stricture recurrence. We examine possible risk factors for stricture recurrence after bulbar UP.

Methods:

596 patients undergoing isolated bulbar UP from August 2003 to June 2015 with complete followup were included in the analysis. UP failure was defined as a recurrent stricture <16 Fr identified on cystoscopy during followup. Potential risk factors examined were patient age, stricture etiology, stricture length, diabetes, smoking, obesity, Charlson comorbidity index, number of previous endoscopic treatments, previous UP, and type of UP. Multivariable binary logistic regression was used to evaluate potential risk factors and determine associations.

Results:

Mean patient age was 44.4 years old. Overall there was a 93.5% stricture-free rate with a mean followup of 63 months. Average stricture length was 3.9 cm. Stricture etiology was most commonly idiopathic (59.4%). 88.1% (525) of patients had failed prior endoscopic treatment while 10.7% (64) failed previous UP. Of the 596 UPs performed, 40.3% (240) were reconstructed using buccal mucosa as an onlay technique, 2.2% (13) were flaps, 28.5% (170) were augmented anastomosis, 27.7% (165) were anastomotic urethroplasties, and 1.3% (8) used combined tissue techniques with successes of 93.8%, 77.0%, 91.8%, 97.0%, and 75%, respectively. On multivariate analysis, decreasing stricture length (p=0.003; OR 1.3; 1.1–1.4), increased patient comorbidity (p=0.018; OR2.8; 1.1–6.5), obesity (p=0.0025; OR2.7; 1.1–6.6), and infectious strictures (p=0.025; OR4.3; 1.2–15.5) increased the likelihood of stricture recurrence. Previous UP (p=0.19), previous endoscopic procedures (p=0.19), type of UP (p=0.88), and individual comorbidities, such as diabetes (p=0.88), smoking (p=0.76), and patient age (p=0.86), did not affect the rate of stricture recurrence.

Conclusions:

Although bulbar UP has a very good (93.5%) stricture-free rate, patients with increased stricture length, increased overall comorbidity, obesity, and strictures of infectious etiology are at increased risk for bulbar UP failure and should be followed more closely for recurrence.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S36.

MP-02.05: The impact of steroid use on artificial urinary sphincter re-operation

Roderick Clark ¹, Jennifer Winick-Ng ², Andrew McClure ², Blayne K Welk ^1,^2,³

Abstract

Introduction and Objectives:

Artificial urinary sphincters (AUS) are used treat male stress incontinence, often following radical prostatectomy. The objective of this study was to determine if oral corticosteroid use was associated with an increased risk of AUS-related reoperation.

Methods:

Administrative data from Ontario was used to conduct a retrospective cohort study. Men >65 years of age who underwent implantation of an AUS between April 1, 2002 and December 31, 2013 were included. Our primary outcome was the first AUS reoperation for any reason. Our primary exposure was a prescription for an oral corticosteroid at the time of AUS implantation or during followup (but prior to the first AUS reoperation); men were considered exposed from the time of the first day of the prescription to 180 days after the last day of the steroid. Our primary analysis was a Cox proportional hazards model with steroid usage modeled as a time-varying covariate.

Results:

We identified 747 men (median age 71, interquartile range (IQR) 68–75), of whom 592 (79.3%) had a prior radical prostatectomy. The median cohort followup was 3.2 (IQR 1.3–5.9) years. 175/747 (23.4%) were exposed to corticosteroids during the study period (median duration of prescription was 22.0 days, IQR 5.0–133.0). We identified an initial AUS reoperation in 176/747 men (23.5%) a median of 1.4 years (IQR 0.4–3.0) after implantation. In our primary analysis, with adjustment for age, radiation exposure, and year of implantation, the hazard ratio for subsequent reoperation on the AUS among steroid users was 1.75 (95% CI 1.08–2.84; p=0.02).

Conclusions:

To our knowledge, this is the first study to demonstrate a significantly increased risk in AUS reoperation among men taking oral glucocorticoids. This risk factor should be considered in patient counselling, and further studies evaluating the specific utilisation patterns of steroids and their association with AUS complications are warranted.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S36.

MP-02.06: Revisiting anastomotic urethroplasty in the era of non-transecting techniques

Keith F Rourke ¹, David Chapman ¹

Abstract

Introduction and Objectives:

Anastomotic urethroplasty is an effective, but occasionally controversial treatment for short bulbar urethral strictures. Non-transecting variations of anastomotic urethroplasty were created in part to address this controversy. The objective of this study is to reassess outcomes of anastomotic urethroplasty and compare transecting and non-transecting techniques.

Methods:

162 patients with complete followup underwent anastomotic urethroplasty from September 2003 to May 2015. The primary outcome was success defined as urethral patency >16 Fr on routine followup cystoscopy. Secondary outcome measures included 90-day complications and de novo erectile dysfunction measured semi-quantitatively at six months. Statistical comparison between transecting and non-transecting cohorts were made using Fischer’s exact and unpaired t-test.

Results:

Mean stricture length was 1.6 cm (range 1–3 cm) with a mean patient age of 44.2 years (18–94). 79.6% of patients failed prior endoscopic treatment and 3.7% failed prior urethroplasty. Preoperative parameters were similar between groups. Overall, there was a 96.9% success rate with a mean followup of 54.2 months. 5.6% of patients experienced a 90-day postoperative complication and 8.6% experienced adverse change in erectile function. Postoperative complications included wound complications (2.5%), scrotal hematomas (1.2%), urethral bleeding (0.6%), urinary tract infection (UTI) (1.2%), chordee (1.2%), and ejaculatory dysfunction (1.2%). When comparing transecting and non-transecting techniques, there was no difference in success (96.2% vs. 100%; p=0.58), de novo erectile function (9.9% vs. 3.2%; p=0.31), or postoperative complications (6.1% vs. 3.1%; p=1.00).

Conclusions:

Anastomotic urethroplasty remains a highly effective treatment for short bulbar urethral strictures with relatively minimal associated morbidity. Newer non-transecting anastomotic urethroplasty techniques appear to compare favourably, with no obvious difference in success or complications.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S37.

MP-02.07: Dorsal onlay vs. a dorsal augmented anastomotic urethroplasty for the long bulbar urethral stricture

Dylan Hoare ¹, David Chapman ¹, Keith F Rourke ¹

Abstract

Introduction and Objectives:

While urethroplasty is the most definitive treatment for urethral strictures, controversy exists regarding the optimal surgical technique for long bulbar disease. Pure onlay grafting avoids transection of the urethra, but may sub-optimally treat obliterative segments at risk for recurrence. Augmented anastomoses involve partial stricture excision in an attempt to remove the most active areas of disease, but may risk vascular compromise through transection of the urethra. This culminates in a theoretical increased potential for erectile dysfunction or morbidity. We performed a retrospective cohort analysis to evaluate outcomes among these two surgical techniques.

Methods:

A 950-patient database was examined for individuals undergoing urethroplasty with buccal mucosa grafts (BMG) for long (2–14 cm) bulbar strictures from 2003 to present. 236 patients received “pure” dorsal onlays with BMG. The augmented anastomosis approach was performed on 143 individuals. Patients were followed longitudinally after their procedures at three weeks with routine cystoscopy and at six months postoperatively in clinic. Our primary outcome was stricture recurrence (<16 Fr).

Results:

Average age at surgery and stricture length were 43.9 ± 14.8 years and 4.8 ± 2.0 cm, respectively, with an average followup of 63.9 ± 36.2 months. Of the dorsal onlay BMG patients, 211 of the 222 (92.9%) followed for greater than six months were found to be stricture-free, whereas 132 of the 140 (94.3%) undergoing the augmented approach did not experience stricture recurrence (p=0.662). There was no significant difference between the cohorts with respect to 90-day complication rates (4.95% vs. 2.80%; p=0.421) or worsening of erectile function postoperatively (4.21% vs. 3.65%; p=1.00).

Conclusions:

There is no significant difference in stricture-free success for patients undergoing dorsal onlay or augmented anastomosis urethroplasty procedures for long bulbar urethral strictures.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S37.

MP-02.08: Pediatric bladder augmentation: Panacea or Pandora’s box?

James Ross ¹, Luis A Guerra ¹, Michael P Leonard ¹, Melise Keays ¹, Christopher S Neville ¹

Abstract

Introduction and Objectives:

There are few longitudinal studies evaluating overall complication rates in children with bladder augmentation. This study reviews our experience with bladder augmentation procedures in the pediatric population and evaluates the complication rate post-bladder augmentation.

Methods:

An Interal Review Board-approved retrospective chart review on all patients who had bladder augmentation at Children’s Hospital of Eastern Ontario (CHEO) between 1990 and 2014.

Results:

56 procedures on 54 patients (28 males, 26 females), mean age 10 (SD 5) and mean followup eight years. Bowel segments included: ileum in 49 (87.5%), ileum/cecum in two (3.6%), and one each (2.0%) of ileum/cecum, stomach, colon, and ureter. Two patients (3.6%) received gastric reservoirs. 28 patients (50%) received catheterizable channels. Postoperative complications included extravasation on cystogram in three (4.1%), bladder perforation in two (3.7%), and wound infection in three (5.6%). Continent channels that required reoperation occurred in 10 of 26 (38%) but eight were skin-stoma-related, usually stenosis. Another two patients had bleeding and one had skin infection. Total complications resulted in return to OR in 19 of 54 (35.2%). During the followup, renal deterioration and electrolyte abnormalities each developed in three (5.6%), stone formation and worsening hydronephrosis each developed in eight (14.8%), hematuria developed in seven (13.0%), and 37 (68.5%) had urinary tract infection (UTI). There were no related deaths.

Conclusions:

Most postoperative complications were minor and commonly associated with the continent conduit, however they required OR revision in a third of the cases and regular followup was necessary. The incidence of serious postoperative complications, including bladder perforation and renal deterioration, was low. The rate of extravasationon the postoperative cystograms was only 4.1% and may be indicated only in selected cases.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S37.

MP-02.09: The effect of an aligning catheter on urethroplasty for pelvic fracture urethral injuries

Alexandra Bascom ¹, Keith F Rourke ¹

Abstract

Introduction and Objectives:

Pelvic fracture urethral injuries (PFUI) typically result in urethral stenosis requiring treatment. The effect of an aligning catheter on subsequent urethroplasty outcomes remains unclear. Our objective is to assess the effect of an aligning catheter on urethroplasty technique and outcomes for PFUI.

Methods:

A retrospective review of urethroplasty for PFUI performed by a single surgeon from 2003 to 2015. Comparison was made between patients with an aligning catheter (Group 1) and suprapubic catheter (SPC) (Group 2). Rates of preoperative and postoperative erectile dysfunction, urethroplasty success, continence, injury grade, difficulty of urethroplasty, and length of stenosis were analyzed.

Results:

60 patients (mean age 40 years) were included for analysis. An aligning catheter was successfully placed in 40% of patients (24) and 56% (34) had placement of a suprapubic catheter. 14 patients (23% total) in the SPC group had a failed aligning catheter. 72% of patients had preoperative erectile dysfunction (ED) which did not differ between groups (p=0.24). Patients with an aligning catheter were more likely to have strictures <2 cm (43% vs. 14%; p=0.05) and to undergo a “simple” urethroplasty compared to those with an SPC (83% vs. 56%; p=0.05). Urethroplasty success (87.3%; p=0.69) and occurrence of postoperative incontinence (5.5%; p=1.0) did not differ between groups with 74 months followup. Adverse change in postoperative ED did not differ between groups (81.8% vs. 62.5%; p=0.15). However, when excluding those patients failing an aligning catheter (from the SPC group) there was a significant difference in postoperative ED (81.8% vs. 47.3%; p=0.03). Those with a complete vs. partial urethral transection at initial assessment were more likely to receive a SPC (97% vs. 41%; p=0.0001).

Conclusions:

Placement of an aligning catheter for PFUI results in a shorter stenosis and higher likelihood of a “simple” urethroplasty. While there is no difference in stricture recurrence or incontinence when excluding those failing aligning catheter, there are higher rates of postoperative ED. It may be important to distinguish between the three different patient PFUI populations: those with an aligning catheter, a primary SPC, and those failing an aligning catheter.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S37–S38.

MP-02.10: Outcomes of split-thickness skin graft reconstruction for major genital skin loss: The adverse impact of systemic disease processes

Keith F Rourke ¹, Ryan McLarty ¹

Abstract

Introduction and Objectives:

Major genital skin loss is a devastating clinical event. Our objective is to report clinical outcomes of genital reconstruction using split-thickness skin grafts (STSG) for various local and systemic disease processes.

Methods:

31 male patients underwent genital STSG reconstruction from 2006–2015. The primary outcome was success defined as patient satisfaction with acceptable cosmesis, preserved standing micturition, and erectile function. Etiology, age, graft take, 90-day and delayed complications, and semi-quantitative assessment of patient satisfaction, cosmesis, erectile, and voiding function were assessed.

Results:

Mean age was 48 years (range 19–80) and the most common etiology of genital skin loss was infection (41.9%), followed by buried penis (25.8%), neoplasia (16.1%), and lymphedema (16.1%). Reconstruction of the penis, scrotum, or both was performed in 71.0%, 19.4%, and 9.6% of patients, respectively. Overall success was 87.1% with a mean followup of 18 months. 90.3% of patients reported satisfaction and acceptable cosmesis. 96.1% of applicable patients reported preserved erectile function (25/26) and 96.3% standing micturition (26/27). 93.5% of patients experienced good (>90%) graft take with timely maturation, but 64.5% experienced a 90-day complication. 95% of early complications were Clavien 1–2, including focal epidermolysis (32.2%), cellulitis (12.9%), urinary tract infection (3.2%), or hematoma requiring observation (3.2%). One patient (3.2%) required surgery for abscess debridement and repeat grafting. Specific etiologies did not impact success, but patients with systemic disease processes were more likely to experience 90-day complications (100% vs. 56%; p=0.04) or impaired graft take (33% vs. 0%; p=0.003).

Conclusions:

Reconstruction with STSG is an effective method for functional reconstruction of major genital skin loss with acceptable morbidity. Patients with systemic disease processes are more likely to experience 90-day complications and delayed graft take.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S38.

MP-02.11: Renal injury does not affect clinical outcome in pediatric multi-organ abdominal trauma

Damian Dylkowski ¹, Luis A Guerra ¹, Melise Keays ¹, Michael P Leonard ¹

Abstract

Introduction and Objectives:

Most pediatric renal trauma can be safely managed conservatively. The impact of renal trauma on the outcome of concurrent intra-abdominal organ injury is not well-studied. We evaluated the impact of renal trauma in children with concurrent, blunt, abdominal multi-organ trauma at a tertiary-care children’s hospital. We hypothesized that concurrent renal injury would not affect clinical outcome.

Methods:

Internal Review Board-approved retrospective review of pediatric patients with multi-organ abdominal trauma (adrenal, spleen, liver, kidney, pancreas, bowel) from 1999–2014. Injury Severity Score (ISS) trauma score, need for intervention, transfusion, and length of stay (LOS) were compared in patients with and without renal injury. Fisher’s exact test was used for categorical data and t-test was used for continuous variables, with significance level p<0.05.

Results:

Of 210 patients (154 male/56 female) with abdominal trauma, 63 had renal injury (47 male/16 female) (Group A) and 147 no renal injury (107 male/40 female) (Group B). Patients in both groups had comparable average ISS scores: A=12.76, B=12.41; p=0.74; and average LOS (days): A=5.8, B=5.6; p=0.82. There was no significant difference between groups regarding transfusion: A=7/63, B=10/147; p=0.29; or operative intervention: A=10/63, B=24/147; p=1.0. Intervention comprised: open surgery A=2/10, B=20/24; laparoscopy A=0, B=3/24; endoscopy A=4/10, B=0; and embolization A=4/10, B=1/24.

Conclusions:

Our study shows that concurrent renal trauma in the pediatric multi-organ abdominal trauma patient does not substantially affect ISS score. In addition there is no difference in clinical outcomes, including operative intervention, transfusion requirement, and LOS. Most interventions for renal trauma are endoscopic and radiological, while intervention for other intra-abdominal organ injuries more commonly comprise laparotomy or laparoscopy.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S38.

MP-02.12: Urethrovaginal fistula repair: Long-term experience

Sender Herschorn ¹

Abstract

Introduction and Objectives:

Urethrovaginal fistula (UVF) is not highly prevalent in urologic practice, but merits attention. There are few large series reported. This is a review of management of all women with UVFs that have been treated to assess etiology, management, and outcomes.

Methods:

A total of 34 UVFs were reviewed retrospectively. Clinical presentation, prior repair, surgical approach, complications, result, and long-term lower urinary tract symptoms (LUTS) were recorded. All UVFs were closed in three or more layers. A variety of flaps were used. A suprapubic or foley catheter was left for four to six weeks.

Results:

Mean patient age was 48.2 years (range 21–81). 12 (34.8%) were long-time smokers. Three had previous pelvic malignancies. 28 (82.3%) patients had undergone other pelvic surgery. The most common etiology was an incontinence procedure in 12 patients (35.3%) with mesh erosion in six. Other causes were forceps delivery in five (15%), urethral diverticulum repair in five (15%), self-intermittent catheterization in three (10%), cystectomy and neobladder in two (6%), and other vaginal surgery in one (3%). 31 were closed via a transvaginally, including 13 with simultaneous rectus fascia pubovaginal slings. Two were approached transabdominally and one was a combined abdominal and vaginal approach. 13 were done with flaps, Martius in 10 and omentum in two. 32/34 (92.15) had success ful repairs. Mean followup was 39 months (range 0.8–207.33). Long-term urinary frequency was seen in 11 (32.3%), urgency in 10 (29.4%), urgency incontinence in eight (24%), and stress incontinence in six patients (17.6%). Switching from suprapubic to Foley catheter drainage did not change success rate.

Conclusions:

UVFs usually result from a surgical complication. Smoking may be a risk factor. Management that optimized outcome included adequate surgical exposure, multi-layer closure usually with flaps and/or rectus fascial sling, and catheter drainage. Tailoring the procedure to the patient appeared to be of benefit.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S38.

UP-02.01: Shortcomings of radiological assessment of Wilms’ tumour volume (using CT and MR) in the preciction of tumour weight on the pathology specimens

Veridiana Andrioli ¹, Michael P Leonard ¹, Melise Keays ¹, Raveena Ramphal ², Ahmad Nasr ³, Dina El Demellawy ⁴, Nishard Abdeen ⁵, Luis A Guerra ¹

Abstract

Introduction and Objectives:

Previous knowledge of Wilms’ tumour volume diagnosed by imaging is an important tool to assess the degree of surgical challenge, morbidity, and treatment planning. We aimed to evaluate the relationship between the volumes of Wilms’ tumours measured preoperatively on cross-sectional imaging (magnetic resonance (MR) or computed tomography (CT)) and the specimen weight at pathology.

Methods:

Patients from a single institution, younger than 18 years of age, diagnosed with Wilms’ tumour who had available pathology reports, as well as MR or CT were included. A urologist and pediatric radiologist independently measured the AP, transverse, and cranio-caudal diameters of the tumours according to a preset protocol. Volumes were calculated using formula for an ellipsoid (APxCCxTRx0.532) and compared with the tumour’s weights on the pathology specimen. Correlation was assessed using linear regression and inter-observer agreement was assessed with a Bland Altman plot.

Results:

31 patients were included. The correlation between radiologic volumes and pathologic weights was initially R2=0.72, but with the exclusion of four lesions that had more than 50% cystic or hemorrhagic components, the correlation improved to R2 value of 0.94. Bland Altman plot showed a mean difference of 6 cc (+/− 151 cc) with 95% limit of agreement between the two assessors.

Conclusions:

Radiologic assessment of Wilms’ tumour volume is highly correlated to tumour weight on pathology specimen in solid lesions and has a good inter-rater agreement, however, this does not appear to hold true for tumours with large cystic and hemorrhagic component.

References

1.Pasha TJ, et al. Correlation between CT-estimated tumour volume, pathologic tumour volume, and final pathologic specimen weight in children with Wilms’ tumour. J Pediatr Urol. 2014;10:148–54. doi: 10.1016/j.jpurol.2013.08.001. [DOI] [PubMed] [Google Scholar]
2.Cohen MD, Weber T, Grosfeld J. Preoperative evaluation of pediatric abdominal tumour volumes by computerized tomography. J Pediatr Surg. 1984;19:273. doi: 10.1016/S0022-3468(84)80184-0. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S39.

UP-02.02: The effect of childhood surgery on adult hypospadias presentation and complications

Nathan Hoy ¹, Keith F Rourke ¹

Abstract

Introduction and Objectives:

Males with hypospadias are likely at increased risk for future urologic complications as adults. However, it is unclear how childhood surgery modifies this risk. The purpose of this study is to describe the spectrum of adult presentations with hypospadias-related complications and examine the effect of childhood surgery on these complications.

Methods:

A retrospective chart review over a 10-year period, from August 2004 to December 2014, demonstrated 93 adult patients who presented to a reconstructive urologist with urologic complications related to hypospadias. Patients were divided into two groups: those with no prior hypospadias surgery (Group 1, n=19) and those who underwent surgical correction as a child (Group 2, n=74). Charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required.

Results:

The mean age at presentation was 34.6 years. Overall, lower urinary tract symptoms (LUTS) (49.5%) was the most common presenting complaint, followed by spraying (23.7%), urethrocutaneous fistula (18.3%), recurrent urinary tract infection (UTI) (15.1%), and chordee (14%). Group 2 patients were more likely to present with LUTS (55.4% vs. 26.3%; p=0.04) and recurrent UTIs (18.9% vs. 0%; p=0.05). Contrastingly, Group 1 patients presented more commonly with cosmetic dissatisfaction (15.8% vs. 4.1%; p=0.04). Urethral stricture disease was demonstrated more commonly in Group 2 (47.3% vs. 10.5%; p=0.004). Of these, strictures were significantly longer in the previous surgery group (5.5 cm vs. 3.0 cm; p=0.02). Surgical intervention was required in 31.6% of Group 1 and 56.8% of Group 2 (p=0.07).

Conclusions:

Correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent UTIs, and subsequent LUTS, but improves patient satisfaction with cosmesis. Followup of hypospadias repair patients should extend into adulthood, as a significant portion of adult presentations ultimately require surgical intervention.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S39.

UP-02.03: Complications of pediatric extirpative renal surgery: Analysis using the Clavien system

Naimet Naoum ¹, Rakan Odeh ¹, Frank J Penna ¹, Ibraheem Abu Azzawayed ¹, Armando J Lorenzo ¹, Walid A Farhat ¹, Darius J Bagli ¹, Martin A Koyle ¹

Abstract

Introduction and Objectives:

Extirpative renal surgery (ERS) in children is most commonly performed for malignancy and benign congenital anormalies associated with poor or non-functioning segments. We present and analyze here complications following total and partial ERS using the Clavien system.

Methods:

A retrospective analysis of the charts of patients, aged 0–18 years, who underwent ERS over a 10-year period (2005 to 2014) was performed, including: open and minimally invasive; partial and total nephrectomies. Transplant allograft nephrectomies were excluded. Complications were classified using the Clavien system. Results were evaluated for: indication, laterality, age, gender, method of ERS (open/minimally invasive), total or partial nephrectomy, and preoperative Hb. Univariate and multivariate analysis were used.

Results:

284 kidneys in 262 patients were evaluable. 48.1% were right-sided. Mean patient age was 6.2 years, with 55.7% being female. Malignant conditions constituted 39.3% of total cases. 50.4% were performed as open surgeries, and 78.2% were total nephrectomies done for malignant conditions in 35.1% of cases. Complications occurred in 24.4% of patients: 18.8% Clavien I, 64.0% Clavien II, 1.6% Clavien IIIa, and 15.6% Clavien IIIb. The most common complication was bleeding (51.4%). There were no mortalities. In univariate analysis, complications occurred more significantly in open total nephrectomy vs. laparoscopic (p 0.0001), bilateral surgeries (p 0.02), partial more than total (p 0.005), partial for malignant more than those for benign (p=0.005), low preoperative Hb <12 gm (p=0.0003), and in malignant cases (p=0.002). On multivariate analysis, only low preoperative Hb was found significant (p 0.05).

Conclusions:

Complications are not infrequent in pediatric ERS, although mostly Clavien I and II, which can be managed without surgical intervention. Low preoperative Hb, malignancy, and bilateral cases are associated with the highest risk for postoperative complications. Laparoscopic approach to ERS may minimize complications risk.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S39.

UP-02.04: Postoperative fever in the pediatric patient undergoing total or partial nephrectomy for a benign pathology: Should we care?

Monica Salgado ¹, Brousseau Tomy ^1,², Anne-Marie Houle ^1,², J Diego Barrieras ^1,², Julie Franc-Guimond ^1,²

Abstract

Introduction and Objectives:

Fever above 38°C is common in the first days after surgery. Most early postoperative fever is caused by the inflammatory response to the surgery itself and resolves spontaneously within two to four days.¹Although nephrectomies in children are procedures with a low complication rate, febrile episodes after surgery include infectious and noninfectious conditions. Differential diagnosis can lead up to septic workups with moderately invasive investigations, which might cause concerns for both the medical team and family. We sought to determine the postoperative rate of febrile episodes for total and partial nephrectomies among both groups and evaluate the necessity to investigate all febrile episodes in the postoperative period.

Methods:

A retrospective review of patients undergoing nephrectomy for benign renal disease between 2000 and 2015 was conducted in a single centre. Demographics were assessed and outcomes evaluated, including fever (temperature >38°C) and post-operative complications. Patients were stratified into two groups: partial nephrectomy vs. total nephrectomy and subgroups (open vs. minimally invasive approach). Differences between groups were analyzed using Fisher’s exact test, X2 test, and multivariate logistic regression. In all tests, p<0.05 was considered to indicate statistical significance.

Results:

A total of 129 patients were identified (76 females, 53 males), including 87 (67.4%) total nephrectomies and 42 (32.6%) partial nephrectomies. No differences were noted in their baseline characteristics. The median age at surgery was 46 months (range 1–180 months). Pyrexia (range 38–39.9°C) developed in 61 patients (47.2%). The incidence was markedly higher in the partial nephrectomy group (66.6%) compared to the total nephrectomy group (37.9%) (p<0.05). Regarding postoperative complications, only three patients developed urinary tract infection in the open nephrectomy group vs. one in the minimally invasive group.

Conclusions:

Most febrile episodes for both groups occurred, as expected, during the first three postoperative days. Interestingly, the proportion of fever was more important in the partial nephrectomy group. However, we did not find significant difference with regards to the surgical approach. Considering there were no serious complications associated with these febrile episodes, one can conclude that observation may suffice in most cases. Regarding the differences, one can postulate that the resected margin may release more inflammatory markers. Larger trials could further delineate this.

References

1.Lesperance R, Lehman R, Lesperance K, et al. Early postoperative fever and the “routine” fever workup: Results of a prospective study. J Surgl Res. 2011;171:245–50. doi: 10.1016/j.jss.2010.03.009. [DOI] [PubMed] [Google Scholar]
2.Barie PS, Hydo LJ, Eachempati SR. Surgical infections. Summer. 2004;5:145–59. doi: 10.1089/sur.2004.5.145. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S40.

UP-02.05: Impact of endovascular ablation of renal nerves in patients with loin pain hematuria (LPS): Prairie LPS study

Francisco J Garcia ¹, Bhanu Prasad ², Kunal Goyal ³, Jennifer StOnge ²

Abstract

Introduction and Objectives:

Loin pain hematuria syndrome (LPHS) is a painful and incapacitating condition that typically afflicts young women. Treatment options are either opiates and/or surgical denervation of the renal nerves that includes auto transplantation or even nephrectomy with varying success.

Methods:

Three patients between the ages of 28 and 62 years (all female) with LPHS underwent endovascular ablation of the renal nerves between July and November 2015 using the Vessix™ renal denervation system. The number and frequency of pain medications, EQ-5D, McGill Pain Questionnaire, Geriatric Depression Score, Short Form (SF)-36, and Oswestry Disability Index were measured at baseline and at three months post-procedure to evaluate changes in pain, disability, quality of life, and mood.

Results:

There were improvements in pain (McGill Pain Questionnaire), disability (Oswestry Disability Index), and quality of life (EQ-5D and SF-36) from baseline to three months post-procedure. Two-thirds of patients were off all pain medications, while one-third had a 70% reduction in the dose.

Conclusions:

We conclude that endovascular ablation of renal nerves is associated with a decline in the number of pain medications and considerable improvement in quality of life and pain. These results suggest that percutaneous catheter-based delivery of radiofrequency energy is a safe, rapid, treatment option that should be considered in all patients with LPHS.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S40.

UP-02.06: Long-term results and safety of polyacrylamide hydrogel for the endoscopic treatment of vesicoureteral reflux in children

Sophie Ramsay ¹, Anne-Sophie Blais ¹, Fannie Morin ¹, Katherine Moore ¹, Stéphane J Bolduc ¹

Abstract

Introduction and Objectives:

Polyacrylamide hydrogel (PAHG) has been shown to offer a good short-term success rate for the endoscopic treatment of vesicoureteral reflux (VUR) in children. Our objective was to provide long-term results focusing on the safety of PAHG.

Methods:

We performed a prospective study using PAHG to treat VUR Grades I to V in children. All patients underwent endoscopic subureteral injection of PAHG, followed by a three-month postoperative renal ultrasound (US) and voiding cystourethrogram (VCUG), and US was repeated at 12 and 36 months. Treatment success was defined as the absence of de novo or worsening hydronephrosis and absence of VUR. Safety elements included new or worsening hydronephrosis, calcification of the injected material, and urinary tract infection (UTI).

Results:

85 children underwent an endoscopic injection with PAHG. Eight were lost to followup after three months and were excluded. For the remaining 77 patients (124 ureters, 53 females), 47 had bilateral VUR and 30 had unilateral VUR. Mean age at surgery was 4.5 years and mean followup was 33 months. Mean injected volume of PAHG was 1.1 ml. The overall success rate three months after a single treatment was 71%. During long-term followup, 68/70 eligible patients underwent the 12-month US, and 40/46 eligible patients underwent the 36-month US. No upper tract deterioration or bulking agent calcifications were reported. Nine patients (12%) presented a non-febrile UTI and two patients (2.6%) had febrile UTI during followup, including one late recurrence of VUR (reinjected).

Conclusions:

The success rate of PAGH in endoscopic injection for VUR treatment is comparable to published results on dextranomer hyaluronic acid. The long-term safety data provides further support for the use of this non-particulate bulking agent, which is less prone to calcifications, to treat VUR in children. The potential lower cost of PAHG makes it an interesting option.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S40–S41.

UP-02.07: Prognostic factors of chronic renal insufficiency in patients with posterior urethral valves

Monica Salgado ^1,², Yann Y Chaussy ¹, Pierre-Alain Hueber ^1,², Anne-Marie Houle ^1,², J Diego Barrieras ^1,², Julie Franc-Guimond ^1,²

Abstract

Introduction and Objectives:

Posterior urethral valve (PUV) is the most common cause of congenital bladder outlet obstruction and chronic kidney disease (CKD) in the male pediatric population. The aim of this study is to determine the prognostic value of nadir creatinine during the first year of life and all other potential factors that might increase the likelihood of developing CKD in patients with this condition.

Methods:

Hospital records of all patients with PUV were reviewed from 1980 to 2010. All patients underwent endoscopic valve ablation. Abnormal kidney function was defined as CKD Stage 2 or higher. Studied variables included: Age at diagnosis, nadir creatinine at first year of life, glomerular filtration rate, renal ultrasound and voiding cystourethrogram findings. Univariate and multivariate analyses were conducted in order to identify independent prognostic factors for CKD. Statistical significance was defined as p<0.05.

Results:

A total of 114 PUV patients satisfied our inclusion criteria. At diagnosis, the mean age was 2.9 years. Among them, 32.5% were diagnosed antenatally, 23.7% before one year of life and 43.9% after. Urinary tract infections (UTIs) were more common at diagnosis (36%). Initial ultrasound showed bilateral hydronephrosis in 42.1% of patients and loss of the corticomedullary differentiation in 24.5% of patients. Vesicoureteral reflux was present in 34.2%, and 31.5% of patients had bladder dysfunction. The mean followup period was 7.9 years (SD 4.61). An abnormal kidney function was found in 18.4% patients, among them 4.38% reached end-stage renal disease. Patients developing CKD were more likely diagnosed before one year of life (80% vs. 20%). The mean of nadir creatinine at first year of life in patients who developed CKD was 54.14 µmol/l vs. 27.48 µmol/l for patients with normal renal function. Diagnosis before one year of age, elevated nadir creatinine at first year of life, bilateral hydronephrosis, recurrent UTIs, and loss of corticomedullary differentiation were significant predictors of renal outcome on univariate analysis. Presence of vesicoureteral reflux, incontinence, and nadir creatinine after endoscopic valve resection had no significant correlation with CKD.

Conclusions:

Posterior urethral valve disease can lead to deleterious effects on long-term renal function. Nadir creatinine at first year of life was the only independent predictor of CKD on multivariate analysis. Nonetheless, age at diagnosis, presence of UTI, and radiological findings on ultrasound represent important prognostic factors that should be taken into consideration in order to optimize patient management.

References

1.Coleman R, King T, Nicoara CD, et al. Nadir creatinine in posterior urethral valves: How high is low enough? J Pediatr Urol. 2015;11:356.e1–5. doi: 10.1016/j.jpurol.2015.06.008. [DOI] [PubMed] [Google Scholar]
2.Coleman R, King T, Nicoara CD, et al. Combined creatinine velocity and nadir creatinine: A reliable predictor of renal outcome in neonatally diagnosed posterior urethral valves. J Pediatr Urol. 2015;11:214.e1–3. doi: 10.1016/j.jpurol.2015.04.007. [DOI] [PubMed] [Google Scholar]
3.Lemmens AS, Mekahli D, Devlieger R, et al. Population-specific serum creatinine centiles in neonates with posterior urethral valves already predict long-term renal outcome. J Matern Fetal Neonatal Med. 2015;28:1026–31. doi: 10.3109/14767058.2014.942278. [DOI] [PubMed] [Google Scholar]
4.Sarhan OM, Helmy TE, Alotay AA, et al. Did antenatal diagnosis protect against chronic kidney disease in patients with posterior urethral valves? A multicentre study. Urology. 2013;82:1405–9. doi: 10.1016/j.urology.2013.07.058. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S41.

UP-02.08: Ultrasound prior to urology referral for suspected cryptorchidism: A wasteful practice

Carolyn Wayne ¹, Melise Keays ^1,², Luis A Guerra ^1,², Michael P Leonard ^1,²

Abstract

Introduction and Objectives:

Undescended testis (UDT) is the most common genital abnormality identified in male infants and a frequent cause for referral to pediatric urology. Patients may have already undergone an ultrasound (US) ordered by the referring physician before consultation. It is our hypothesis that this practice is common, costly, and inaccurate for testis localization. Our objective was to determine the proportion of boys referred for suspected UDT who had accompanying US, the cost of this practice, and the accuracy of US for testis localization.

Methods:

We retrospectively reviewed the charts of all patients referred to a tertiary-care pediatric urology service for suspected UDT from 2008–2012. We noted whether or not an US was ordered before referral and compared the location of the testis on US to the urologist’s examination (normal/retractile, inguinal, or impalpable). Additionally, we calculated the cost of US ordered for this referred cohort using the current OHIP fee schedule.

Results:

We identified 894 eligible patients; 289/894 (32%) were accompanied by US. In 223/289 (77%), the urologist was able to palpate the testis: 147/289 (51%) had a normal/retractile testis and 76/289 (26%) had a palpable undescended testis. At a cost of $71.10 per US, $20 547.90 was expended on this practice. Of the 223 patients with palpable testes, we were able to gather detailed US and physical examination results for 214 (138 normal/retractile testes, 76 palpable UDT). In 131/214 (61%), the US results did not correlate with the urologist’s findings. Interestingly, in 116/138 (84%) patients with normal/retractile testes, the US showed at least one inguinal testis. In fact, in 22/214 cases (10%), the US incorrectly identified a normal testis as inguinal on the side contralateral to that of concern.

Conclusions:

Referral of patients for suspected UDT should not be accompanied by an US study, as this is an unnecessary and wasteful practice.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S41.

UP-02.09: Child and parent questionnaires evaluating a bladder training video or standard urotherapy in improving symptoms of bladder bowel dysfunction

Christine Li ¹, Mandy Rickard ¹, Natasha Brownrigg ¹, Bethany Easterbrook ¹, Kizanee Jegatheeswaran ¹, Jorge E DeMaria ¹, Armando J Lorenzo ², Luis H Braga ¹

Abstract

Introduction and Objectives:

Bladder bowel dysfunction (BBD) is a common pediatric urology referral. A randomized, controlled trial was recently completed at our institution to compare a bladder training video (BTV) to standard urotherapy (SU). Herein, we examine patient and parent evaluations of BTV and SU to explore their perceptions of the two urotherapy modalities.

Methods:

Patients and their caregivers currently enrolled in a trial evaluating BTV vs. SU completed questionnaires three months following urotherapy to determine perceived effectiveness, urotherapy engagement, and self-reported progress. BBD symptomology scores and quality of life (QoL) using the Vacounver questionnaire and PinQ Qol, respectively, were measured at baseline and followup. Responses to evaluation questionnaires were correlated to symptomology and QoL scores using simple regression models. Student t-tests were used to compare responses between groups.

Results:

Of 122 patients that completed the trial, 114 (93%) returned the evaluation questionnaires with equal response rates for both groups. Patients in SU compared to BTV found the urotherapy information difficult to understand (28% vs. 2%; p≤0.01). The parent questionnaire demonstrated that while information in both groups was found to be clear, children had significantly more difficulty applying information in the SU group (p=0.05). Children in the BTV group felt significantly more empowered to fix their BBD (p<0.05). Despite this, both treatment groups showed improved symptomology (BTV: 5.9 ± 0.76, SU: 6.2 ± 0.77) and QoL (BTV: 6.1 ± 1.7, SU: 3.7 ± 1.7) scores. Patients who were actively engaged in implementing urotherapy strategies were more likely to see improvement in BBD symptoms (p<0.01) and QoL (p<0.05) regardless of modality compared to those who were not as engaged.

Conclusions:

Although patients in both groups showed improvement in BBD symptoms and QoL, BTV may be a more child-friendly means of delivering urotherapy than SU according to patients’ and caregivers’ perceptions.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S41.

UP-02.10: Outcome analysis of redo orchiopexy: Scrotal vs. inguinal approaches

Naimet Naoum ¹, Roberto I Lopes ¹, Michael Chua ¹, Thomas Canil ¹, Joana Dos Santos ¹, Walid A Farhat ¹

Abstract

Introduction and Objectives:

Surgical management of secondary undescended testis by both scrotal and inguinal orchiopexy has been shown to be successful with limited complications. Herein, we report our experience with redo orchiopexy in children, aiming to analyze the outcome of the two approaches.

Methods:

After obtaining Research Ethics Board approval, we did a retrospective review capturing patients who underwent a redo orchiopexy at a single centre between January 2004 and May 2015. Variables evaluated included primary procedure, operative time, rate of conversion, operative complications, and testicular location at last followup. 3384 orchiopexies were performed in this study period, with 61 patients having undergone a redo orchiopexy (1.8%). Mean patient age was 6.4 years (range 1.5–17.1), and mean followup period was 21.9 months (range 2.1–99.6). The primary surgical procedure preceding the redo surgery was inguinal orchiopexy in 45.9%, scrotal orchiopexy in 13.1%, laparoscopic approach in 13.1%, or status post-inguinal surgery in 27.9%. In 33 patients, redo surgery was performed by an inguinal approach, while 28 children had scrotal approach. No statistical difference in both intra-and postoperative complication rates was found for the two approaches (p=0.7, p=0.6, respectively). Apart from the additional incision in the inguinal group, the complications found included scrotal/testicular tear, atrophy, inadequately positioned testes, and orchiectomy. The overall operative time was statistically diffrent (p=0.002), with scrotal orchiopexy being significantly shorter at an average of 53.1 ± 22.2 minutes compared to inguinal at 84.6 ± 52.3 minutes. The testes ended at the bottom of the scrotum without complications in 54.8% when operated on inguinally and in 65.2% when operated on scrotally, though this difference was not found significant (p=0.6).

Conclusions:

Both scrotal and inguinal orchiopexy appear to be viable in the management of secondary ascending testis, with scrotal approach offering some advantage in terms of the procedure length.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S41–S42.

UP-02.11: Associations of initial SFU grades and UTD risk groups with clinical outcomes in patients with isolated prenatal hydronephrosis

Luis H Braga ^1,², Melissa McGrath ^1,², Kizanee Jegatheeswaran ^1,², Bethany Easterbrook ^1,², Mandy Rickard ^1,², Nathan C Wong ^1,², Jorge E DeMaria ^1,², Armando J Lorenzo ³

Abstract

Introduction and Objectives:

The 2014 Urinary Tract Dilation (UTD) classification was proposed to address shortcomings of the Society for Fetal Urology (SFU) grading system.¹ We compared initial SFU hydronephrosis (HN) grades vs. UTD risk groups in relation to future surgery and fUTI rates in infants with isolated HN.

Methods:

We prospectively screened 879 patients with prenatal HN between 2009 and 2015. We only included patients with ureteropelvic junction obstruction (UPJO)-like HN (n=305); megaureter (60), vesico-ureteral reflux (VUR) (83), other genitourinary (GU) anomalies (118), presentation >12 months (195) and HN resolution at first visit (118) were excluded. SFU and UTD grades were collected at baseline, surgery and last followup. Primary outcomes were pyeloplasty and fUTI rates.

Results:

Mean age at first visit was 3.3 ± 2.6 months and mean followup was 21 ± 17 months. About 82% were males (n=249), of whom 35% were circumcised. Mean APD for surgically vs. conservatively managed patients was 24 ± 11 mm and 10 ± 6.5 mm, respectively. Pyeloplasty was performed in 34% patients with SFU III–IV and 32% of those with UTD 2/3 (p=0.88). Rates of fUTI in SFU III–IV patients were similar to UTD 2/3 (11% vs.12%; p=1.00). Children with SFU III–IV had a significantly higher rate of surgery (34% vs. 2%; p<0.01) and fUTI (32% vs. 1.5%; p<0.01) compared to SFU I–II. Similar findings were seen with the UTD groups comparing low- (1) vs. mod/high-risk patients (2/3). Rates of fUTI and pyeloplasty in infants with UPJO-like HN according to SFU and UTD are displayed in Table 1. Survival curves of time to pyeloplasty and time to fUTI comparing SFU I/II vs. III/IV and UTD 1 vs. 2/3 are shown in Fig. 1.

Conclusions:

Both grading systems equally allowed for risk stratification and prediction of clinical outcomes, correctly separating infants who underwent surgery or developed fUTI from those managed conservatively. Use of the new UTD compared to SFU should not affect how families of children with prenatal HN (UPJO-like) are counselled regarding need for surgery and fUTI risk.

Table 1.

UP-02.11. Rates of fUTI and pyeloplasty in patients with UPJO-like according to SFU grades and UTD risk groups

Grading system	Pyeloplasty n=56 (%)	Conservative n= 249 (%)	Total (n=305)
SFU I	0 (0)	38 (100)	38
SFU II	3 (3)	107 (97)	110
SFU III	19 (17)	91 (83)	110
SFU IV	34 (72)	13 (28)	47
UTD 1	2 (1)	136 (99)	138
UTD 2	16 (14)	98 (86)	114
UTD 3	38 (72)	15 (28)	53

Grading system	UTI n= 22 (%)	No UTI n= 283 (%)	Total (n=305)

SFU I	2 (5)	36 (95)	38
SFU II	3 (3)	107 (97)	110
SFU III	11 (10)	99 (90)	110
SFU IV	6 (13)	41 (87)	47
UTD 1	2 (1)	136 (99)	138
UTD 2	13 (11)	101 (87)	114
UTD 3	7 (13)	46 (87)	53

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References

1.Nguyen HT, Benson CB, Bromley B, et al. Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system) J Pediatr Urol. 2014;10:982–98. doi: 10.1016/j.jpurol.2014.10.002. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S43.

MP-03.01: The interaction of urinary components with biomaterials in the urinary tract: Ureteral stent discolouration

Ben H Chew ¹, Justin Chan ¹, Takahiro Hirayama ², Masatsugu Iwamura ², Neil Branda ³, Dirk Lange ¹

Abstract

Introduction and Objectives:

Ureteral stents are fraught with complications, including infection, encrustation, and significant patient discomfort. Recent studies from Japan suggested that the discolouration of indwelling stents changes their surface characteristics in a way that promotes stent-associated complications. Occasional stent discolouration has been observed, however, not much is known about how it happens and whether it changes the surface characteristic of stents. This work studies mechanisms that lead to stent discoloration and characterizes changes in stent surface characteristics.

Methods:

20 indwelling Polaris Ultra and Percuflex Plus stents (made of the same polymer material) with varying degrees of discolouration were collected from patients in both Japan and Canada. Surface characterization was conducted using scanning electron microscopy, Fourier transmission infrared spectroscopy, and secondary ion mass spectrometry. Conditioning film components from each stent were analyzed using quadrupole time of flight mass spectrometry. Degrees of encrustation of stents removed from patients and artificially discoloured stent pieces were investigated using an established stent encrustation model.

Results:

Stent discolouration was caused by a reaction between sulfur-containing compounds in urine and the bismuth subcarbonate in the stents used to make them radiopaque. It was determined that a reducing agent is also required, making this a reaction involving multiple urinary compounds. Furthermore, no significant changes in the bulk material of discoloured stents were observed compared to non-discoloured stents. No evidence of unusual crystal deposition on the surface of discoloured stents was found.

Conclusions:

Ureteral stent discolouration is triggered by a reaction between bismuth subcarbonate within the stent material and sulfur containing urinary components and does not result in significant changes in the bulk material of indwelling stents.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S43.

MP-03.02: Pre-clinical rationale for combination PI3K and epigenetic pathway inhibition in advanced prostate cancer

Paul J Toren ^1,², Jared Allman ¹, Soojin Kim ¹, Amina Zoubeidi ¹

Abstract

Introduction and Objectives:

The PI3K/Akt pathway is frequently activated in aggressive and resistant prostate cancer. Here, we detail our pre-clinical evaluation of AZD8186, a novel β and δ selective PI3K small-molecule inhibitor. Further, we investigate how increased transcription of the Myc oncogene may represent a targetable mechanism of resistance to monotherapy PI3K/Akt inhibition through targeting of the epigenetic reader BET proteins with JQ1.

Methods:

Human prostate cancer cell lines LNCaP and 22RV1 were tested for sensitivity to AZD8186 in vitro. Caspase-3 activity and flow cytometry were used to assess apoptosis. Western blotting and RT-qPCR were used to measure AR and myc pathway genes and protein expression. Castrate resistant LNCaP xenografts were treated with increasing doses of AZD8186.

Results:

In vitro, LNCaP cells were sensitive to AZD8186, with decreases in cell proliferation and increases in apoptosis. In vivo, there was a dose-dependent decrease in tumour growth velocity with AZD8186 with on-target decreases in pAkt observed in xenograft tumours. Further, increases in Myc protein and mRNA levels were seen in AZD8186-treated xenografts compared to control. Downstream increases in EGFR and IGF-IR mRNA transcripts induced by AZD8186 were also seen in vitro and in vivo. Addition of the BET inhibitor JQ1 decreased the increase of Myc induced by AZD8186 and also partially abrogated the increases in EGFR and IGFR. Greater suppression of PSA expression was seen with the combination of AZD8186 and JQ1 compared to AZD8186 and enzalutamide. Similar results were seen in the 22RV1 cell line.

Conclusions:

Inhibition of PI3K with AZD8186 inhibits growth of PTEN-negative LNCaP cells. However, feedback activation of Myc and AR pathways occur. Our results suggest that combined BET inhibition and PI3K inhibition is a rational combination strategy and further studies are warranted for prostate cancers with an activated PI3K/Akt pathway.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S43.

MP-03.03: Targeting Gli1 and Gli2 in the sonic hedgehog pathway inhibits bladder cancer progression

Peter A Raven ^1,², Sebastian Frees ², Betty Zhou ², Claudia Chavez-Munoz ², Michael Cox ², Alan I So ^1,²

Abstract

Introduction and Objectives:

The sonic hedgehog (SHH) signaling pathway regulates a variety of embryonic developmental processes and abnormal activation of the SHH pathway may lead to an increase in cell survival and metastasis in different cancers, including bladder cancer (BC). Glioma-associated proteins (Gli), a family of transcription factors, have been interrelated with the expression levels of the SHH pathway, suggesting Gli activity is a direct indicator of SHH pathway activity. Here we hypothesize that blockage of SHH pathway may be an efficacious way of stopping BC progression.

Methods:

SHH pathway protein expression was assessed by immunohistochemical staining in our human BC tissue array of superficial, invasive, and lymph node-metastasized transitional cell carcinoma. In addition, a panel of BC cell lines was assessed for SHH pathway activation, function, and responsiveness. Proliferation and cell death were measured in response to small-molecule pathway inhibitors and antisense oligonucleotides (ASO) targeted to Gli 1 and 2. These results were confirmed in a novel in-vivo murine non-muscle invasive BC model.

Results:

An array of human BC tissues showed SHH pathway activation through a significant upregulation of the SHH pathway proteins PTCH, SMO, and Gli1, and Gli2 in invasive BC when compared to non-invasive cancer and normal bladder tissue. Similarly, in a panel of urothelial carcinoma cells lines, Gli1 and Gli2 proteins were highly expressed in more aggressive cell lines (UM-UC3, T24) compared to less aggressive ones (RT4, SV-HUC) . Inhibition of Gli1 and Gli2 signalling with ASO reduced tumour cell proliferation, migration, and invasion in vitro in the more aggressive cell lines. In vivo, GLI2 ASO significantly abrogated tumour growth when compared to control tumours.

Conclusions:

Gli 1 and Gli2 ASO may be a potential new therapy to stop progression and invasion in bladder cancer improving the survival of bladder cancer patients.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S44.

MP-03.04: STAT1 inhibition restored chemotherapy sensitivity in chemoresistant bladder cancer

Tetsutaro Hayashi ^1,², Roland Seiler ¹, Robert H Bell ¹, Susan Ettinger ¹, Kendric Wang ¹, Akihiro Goriki ^1,², Htoo Oo ¹, Shannon Awrey ¹, Manuel Altamirano-Dimas ¹, Akio Matsubara ², Colin Collins ¹, Peter C Black ¹

Abstract

Introduction and Objectives:

Cisplatin-based combination chemotherapy is the standard treatment for patients with advanced bladder cancer (BC). Although responses are observed in up to 60% of patients, these are rarely durable. Therefore, novel targets are essential for designing new treatments. Here, we studied to identify a genomic signature associated with resistance to cisplatin (CDDP) and gemcitabine (GEM), and explore novel therapeutic targets in BC.

Methods:

Three chemosensitive BC cell lines (RT112, UM-UC3, UM-UC13) were treated serially with increasing concentrations of CDDP up to 10 µM, 3.3 µM, 3.3 µM, or GEM up to 10 µM, 10 µM, 0.1µM, respectively in order to establish resistance (CDDP-R and GEM-R). Gene expression microarray analysis of the resistant cell lines compared to the sensitive parental lines was conducted.

Results:

We ranked the top differentially expressed genes between the parental chemosensitive cell lines and the derived chemoresistant cell lines. Genes related to interferon (IFN) signaling made up 10 of the top 15 up-regulated genes. Pathway analysis revealed that IFN/STAT1 signaling is activated in chemoresistant cell lines. Knockdown of STAT1 in these chemoresistant cell lines decreased expression of IFITM1, IFI27, IFI44L, IFI6, IFITM1, and IFIT1, which are downstream target genes of IFN/STAT1 signaling. Next, we studied IFN/STAT1 effect on proliferation in chemoresistant cells. STAT1 knockdown without CDDP/GEM treatment increased cell growth by cell cycle progression. This is accompanied with increased SKP2 and decreased p27. However, STAT1 knockdown with CDDP/GEM treatment decreased cell growth and increased apoptosis, suggesting that STAT1 silencing combined with chemotherapy restored chemotherapy sensitivity.

Conclusions:

IFN/STAT1 signaling is activated in chemoresistant BC cell lines and its inhibition can resensitize to chemotherapy. These genes warrant further study for their potential for rational cotargeting in the context of chemoresistant BC.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S44.

MP-03.05: Development of a bio-layer interferometry-based assay for studying insulin-like growth factor (IGF)/IGF-binding protein interactions

Abdulrahman Alsabban ^1,², Michael E Cox ¹, Mazyar Ghaffari ¹

Abstract

Introduction and Objectives:

The IGF axis is comprised of two hormone growth factors (IGF-I and IGF-II), two cell surface receptors (IGF-IR and IGF-IIR), six high-affinity binding proteins (IGFBP-1 to -6), and several other factors that regulate IGF actions in essentially all tissues. Activation of IGF-IR promotes cell cycle progression and inhibits apoptosis, and has angiogenic and metastatic activities in various cancers. These effects depend on the bioavailability of the IGFs, which is regulated by IGFBPs. Increased IGFBP-2 and IGFBP-5 expression is observed in castration-resistant prostate cancer. We hypothesize that blocking the IGF binding site of IGFBPs can affect the bioavailability of IGFs to target tissues, and thus can be used for treatment of various IGF-responsive diseases, including prostate cancer.

Methods:

We have developed a bio-layer interferometry (BLI)-based in vitro assay to study IGFBP-5/IGF-I binding kinetics. This will allow for high throughput screening of factors that can affect this intermolecular interaction for use as a platform to screen for compounds targeting this and other IGFBPs.

Results:

The assay uses biotinylated IGF-I bound to strepavidin-coated biosensors, which in optimized buffer conditions, bind recombinant IGFBP-5 with high affinity (dissociation rate constant (Kdis) of 1.2 × 10⁻⁴ (1/s)). We found that recombinant IGF-I can efficiently disrupted this interaction (Kdis 1.5 × 10⁻³ 1/s), while the amino-terminal IGF-I mutant, E3R, exhibits an intermediate competitive activity (Kdis 5.51 × 10⁻⁴ 1/s) and insulin exhibits a lower competitive activity (Kdis 5.3 × 10⁻⁴ 1/s).

Conclusions:

Results from the development of this BLI-based IGFBP-5/IGF-I interaction assay demonstrates the capacity to differentiate relative competitive activity of compounds that target the high affinity IGF-I binding site of IGFBPs. This assay will serve as a platform to screen for factors that might be developed as rationale therapeutics to disrupt sequestration of IGF-I by IGFBPs.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S44.

MP-03.06: Targeting heat-shock protein 27 inhibits tumour growth and enhances sensitivity to sorafenib treatment in human renal cancer cells

Sebastian Frees ¹, Claudia Chavez-Munoz ¹, Betty Zhou ¹, Peter A Raven ¹, Ladan Fazli ¹, Kim Chi ¹, Keith Lawson ², Antonio Finelli ², Martin E Gleave ¹, Alan I So ¹

Abstract

Introduction and Objectives:

Novel targeted therapies, tyrosine kinase inhibitors (TKI), have led to significant improvement in outcome of patients with metastatic renal cell carcinoma (mCCRCC). However, eventual drug resistance to TKI universally occurs due to upregulation of non-VEGF genes that allows for tumour progression. Heat shock protein 27 (Hsp27), a chaperone molecule involved in cell stress response, has been shown to be involved in treatment resistance in many malignancies. In this study, we assess the expression of Hsp27 in CCRCC and the effects of knocking down Hsp27 in cCCRCC with or without TKIs.

Methods:

Immunhistochemistry of a tissue microarray from 15 patients treated with sorafenib was stained for expression of Hsp27. Several renal cell lines (CAKI-1, CAKI-2, 7680 and ACHN) were treated with sorafenib and analysed for Hsp27 expression. After specific knockdown of Hsp27 with siRNA and antisense oligonucleotide (OGX-427) cell viability was measured using Presto Blue.

Results:

Staining of the tissue microarray revealed a significant upregulation in the protein expression of Hsp27 after treatment compared to a historical untreated cohort. In human renal cancer cell lines, we were able to observe similar results. Targeting Hsp27 with siRNA and antisense oligonucleotide revealed a decrease in cell viability in combination with sorafenib treatment.

Conclusion:

Treatment of renal cell carcinoma with sorafenib leads to an upregulation of the Hsp27 in-vivo and in vitro. Targeting Hsp27 in combination with sorafenib treatment might lead to better response rates in the treatment of advanced renal cancer.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S44–S45.

MP-03.07: Orthotopic sunitinib-resistant renal cell carcinoma xenograft mouse model

Sebastian Frees ¹, Igor Moskalev ¹, Peter A Raven ¹, Betty Zhou ¹, Claudia Chavez-Munoz ¹, Peter C Black ¹, Alan I So ¹

Abstract

Introduction and Objectives:

Current first-line treatments of renal cell carcinoma (RCC) are tyrosine kinase inhibitors (TKI), such a sunitinib (SU), which target angiogenesis through VEGFR pathway. After an initial response rate of 30–40%, it has been shown an acquired resistance after 6–11 months despite continuous treatment. Most commonly used TKI-resistant animal models are created in vitro, by exposing kidney cancer cells to increasing doses of the drug. To account for the fact that angiogenesis is crucial in the development and treatment of RCC, we developed an in vivo SU-resistant mouse model.

Methods:

Luciferin expressing-CAKI-1 human renal cancer cells were injected under the renal capsule of athymic nude mice using ultrasound guidance. After initial tumour growth, mice were treated with SU at 40 mg/kg, which was increased sequentially (60, 80, and 100 mg/kg) at each tumour passage. Tumours were monitored twice weekly by ultrasound and bioluminescence (IVIS). Tumours exceeding 200 mm³ by ultrasound or 10¹⁰ photons/sec by IVIS were considered endpoints. For each passage, tumours were harvested, dissociated, and injected in single-cell suspension (5 × 10⁵ cells) into the following batch of mice, considering this a cycle.

Results:

Initial treatment of SU at 40 mg/kg showed decrease in tumour size of about 30% using both methods. After 14 days of treatment, tumours started to regrow, despite continuous treatment. In the second cycle, tumours did respond to a subsequent treatment of 40 mg/kg, proving resistance. Even after increasing the dose of SU in the following cycles to 60 and 80 mg/kg, respectively, there was no response observed. 100 mg/kg had to be terminated due to severe side effects in the animals.

Conclusions:

This study describes the first orthotopic xenograft RCC SU-resistant mouse model created in angiogenic in vivo environment, opening the possibility to study not only the mechanism of SU resistance, but also to find alternative therapies to overcome SU resistance.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S45.

MP-03.08: Towards understanding the interplay between androgen receptors, androgens, and IKKε in the tumour growth control of prostate cancer cells

Yannick Huon ^1,^2,³, Benjamin Péant ^1,^2,³, Kim Leclerc-Desaulniers ^1,^2,³, Nathalie Delvoye ^1,^2,³, Anne-Marie Mes-Masson ^2,^3,⁴, Fred Saad ^2,^3,⁵

Abstract

Introduction and Objectives:

Following androgen-depletion therapy, prostate cancer (PCa) can progress from hormone-sensitive (HS) to a castrate-resistant state. We have demonstrated the specific high expression of IKKε in advanced stages of PCa. We are performing experiments to determine whether androgen and hormone dependence influence IKKε function.

Methods:

We used HS 22Rv1 PCa cells that overexpress IKKε in an inducible manner. We injected these cells into SCID mice and compared 72 castrated and 72 uncastrated animals with or without IKKε induction. In order to study the implication of the androgen receptor (AR) itself, we studied the effect of AR knockdown in relation to differential IKKε expression in 22Rv1 cells. Cell proliferation and clonogenic capability were performed.

Results:

Growth of xenografts is decreased when IKKε is expressed, and thus mice survival is increased (p=0.0002). Interestingly, this effect is weakened upon castration, with a reduce effect on mice survival (p=0.0017). In vitro experiments don’t reveal any effect of concomitant IKKε expression and AR knockdown on proliferation and clonogenic ability. In order to more faithfully mimic in vivo castration, we are repeating these results through the chemical inhibition of the AR.

Conclusions:

Our results demonstrate that the presence of androgen concomitant with IKKε expression had a positive effect on the survival of mice. Unexpectedly, this benefit is reduced upon castration, suggesting that the positive tumour growth activity of IKKε is contextual and influenced by androgen. On the other hand, in vitro experiments fail to reveal any differences in oncogenic capability of cells upon IKKε and AR knockdown, although AR signalling inhibition may have a different effect. Alternatively, immune regulatory factors, such as NK cells and macrophages, may contribute to the results seen in xenografts. To address this, we are studying the presence of infiltrating immune cells in our xenografts by immunohistochemistry.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S45.

MP-03.09: CCN3 is a prognostic biomarker and functional mediator of prostate cancer bone metastasis

Matthew R Danker ¹, Veronique Ouellet ², Dru Perkins ¹, Matthew G Annis ¹, Estelle Schmitt ², Zhifeng Dong ¹, Anne-Marie Mes-Masson ², Fred Saad ², Peter Siegel ¹

Abstract

Introduction and Objectives:

CCN3 has been implicated in promoting the formation of osteolytic prostate cancer (PCa) bone metastases. The C-terminal domain (CT) of CCN3 binds growth factors, heparin sulfate proteoglycans, activates Notch signaling, and promotes dimerization of CCN family members. We hypothesize that the CT domain is required to promote osteolytic PCa bone metastasis and that CCN3 represents a prognostic biomarker in primary PCa tumours to predict recurrence to bone.

Methods:

LNCaP C4-2 cells were first tagged with a ZSGreen-Luciferase reporter construct. Tagged LNCaP C4-2 cells were then transduced with control, CCN3 wild-type (WT) or CCN3 CT domain mutant (ΔCT) retrovirus. The cell populations were subjected to intra-cardiac injection in immune-compromised mice. Animals were imaged bi-weekly for bioluminescence (IVIS 1000) and at endpoint by live animal micro-computed tomography scan. To evaluate the expression of CCN3 in human prostate cancer tissue, we accessed the Canadian Prostate Cancer Biomarker Network tissue microarray test series composed of adjacent benign and tumour cores from 250 radical prostatectomy specimens. Immunohistofluorescence was performed followed by a semi-automated image analysis using VisiomorphDP software.

Results:

Intra-cardiac injection revealed bone metastases exclusively in the mandibles, with incidence of 60% in mice injected with vector control cells, 90% with CCN3WT-expressing cells, and 60% with CCN3ΔCT mutant-expressing cells. Ex vivo micro-CT scans have revealed a significant decrease in bone mineral density in the mandibles of mice injected with CCN3WT expressing cells compared to vector control or CCN3ΔCT mutant cells. Meanwhile, immunofluorescence staining with anti-CCN3 antibody of primary prostate tumours was significantly associated with recurrence to bone.

Conclusions:

We conclude that CCN3 promotes the formation of bone metastases in a CT-domain fashion and is a valid biomarker for predicting PCa recurrence to bone.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S45–S46.

MP-03.10: Biomarker validation by immunofluorescence: A novel approach to follow prostate cancer progression

Sylvie Clairefond ¹, Véronique Ouellet ¹, Benjamin Péant ¹, Véronique Barrès ¹, Gabriela Fragoso ¹, Anne-Marie Mes-Masson ^1,², Fred Saad ^1,³

Abstract

Introduction and Objectives:

Prostate cancer (PCa) is the most frequently diagnosed form of cancer and the third leading cause of cancer-related mortality in Canada. As PCa patient management varies widely, there is a need to find putative biomarkers for clinical use to identify patients with poor prognosis, where treatment options would be impacted. In this context, it is necessary to validate biomarkers for stratification of PCa. Our aim is to evaluate several biomarkers by immunofluorescence (IF) and correlate their expression with patient clinical data in order to identify the best prognostic biomarkers, either alone or in combination.

Methods:

Biomarker antibodies (PUMA, NOXA, EGFR, and ErbB3) were verified for specificity using western blots and optimization tissue microarrays, which contain cell lines and xenografts created using human PCa cell lines injected in mice. Quantification of potential biomarker expression was performed on radical prostatectomy samples (286 patients) arrayed as 0.6 mm cores in duplicate. The analysis of biomarker expression was semi-automated using the VisiomorphDP software. Followed-up data (90.5 months) are available for statistical analyses.

Results:

Analysis has been completed for PUMA. As expected from previous results, we found no significant association with the prognosis of PCa patients. The predictive PUMA/NOXA combination that has previously been shown to be prognostic remains under investigation. Two commercial NOXA antibodies were non-specific and a third is in study. The EGFR antibody has been validated and the staining with epithelial markers (CK8 and CK18) and the basal cell marker (p63) is being optimized. The biomarker ErbB3 has been validated and the analyses of expression levels are ongoing.

Conclusions:

Our multimarker approach allows us to quantitatively compare the expression of individual markers within the tumour micro-environment, as well as at the sub-cellular level, providing rich datasets for biomarker selection and validation.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S46.

MP-03.11: Development of a urine-based inflammatory test for prostate cancer

Nikunj Gevariya ^1,², Karine Robitaille ^1,², Alain Bergeron ^1,², Tal Ben-Zvi ^1,², Marc-Andre Allard ^1,², Yves Fradet ^1,², Nicolas Bisson ¹, Vincent Fradet ^1,²

Abstract

Introduction and Objectives:

Chronic inflammation is a potential causal factor of prostate cancer (PCa). However, a non-invasive test assessing prostatic inflammation is inexistent. The aim of this project is to develop a non-invasive urine-based test to measure prostate inflammation and stratify risk of PCa. Specifically, here, we sought to identify proteins, inflammatory-related in particular, only present in post-digital rectal exam (DRE) urine.

Methods:

We collected urine samples before and after DRE in 10 consenting men presenting for prostate needle biopsy. A total of 22 urine samples were passed through shotgun mass spectrometry protocols. First, we optimized conditions in order to specifically analyze secreted proteins. Then, we compared global secreted protein expression of pre- and post-DRE urine samples (total 18 samples) of nine patients (three of each: Gleason (G)8, G6, and without cancer groups) to discover cancer-specific biomarkers of inflammation. Protein abundance were compared using the Welch t-test with p values <0.1 declared significant.

Results:

The condition optimization process defined our protocol to use of 5 µg of protein for a two-hour run duration from undepleted urine samples. We identified 69 proteins greater than two-fold more abundant in post-DRE urine as compared with pre-DRE urine. We identified 50 proteins found only in PCa versus patients without cancer. Of these, four proteins were involved in inflammatory pathways, including known cancer identifiers CD-74 and CD-276, the latter also being an immune-checkpoint. We identified 24 proteins differentially found in G8 versus G6 patients.

Conclusions:

We identified candidate protein signatures of PCa and specifically of high-grade PCa. These must be validated in larger cohorts. Only few of these proteins are implicated in inflammatory pathways making shotgun proteomics not relevant to identify them. Targeted proteomics will be needed to measure inflammatory-related cytokines.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S46.

MP-03.12: A comparative analysis of uropathogen prevalence and susceptibility profiles in a prospectively managed HIV-positive cohort in Dublin, Ireland

Fardod O’Kelly ¹, Dara Lundon ¹, Willard Tinago ^2,³, Alan Macken ², Padraig Daly ¹, Kiaran O’Malley ^1,², Patrick Mallon ²

Abstract

Introduction and Objectives:

Multiple factors impact resistance profiles of uropathogens. The rates vary greatly between countries, where resistance rates to certain antibiotics have reached critical levels. There is no data on the prevalence of urinary tract infections (UTIs) or resistance in HIV-positive populations within the U.K. or Ireland.

Methods:

The institutional prospective database was analyzed, in addition to clinical data for 539 HIV-positive patients. Prevalence, pathogenicity, and clinicodemographic characteristics were collated. Statistical analysis was carried out with SPSS (IBM).

Results:

The cohort comprised of 539 patients, 314 (58.26%) of whom were male, with females occupying significantly more of the culture-positive MSU (+MSU) group (76.7%) (p<0.001). The median age (at the time of anti-retroviral treatment (ART) initiation) was 40 years, and there was no significant age difference between groups. Controlling for other factors, a positive MSU was statistically more likely in Caucasians (adjusted odds ratio (OR) 3.54, 95% CI 1.31; 9.57), females (OR 11.01, 95% CI 4.67; 25.94), with advancing age (OR 1.75/10-year increment, 95% CI 1.10; 2.77), and with intravenous /injecting drug use (IVDU) (OR 5.96, 95% CI1.54; 23.14). There was no significant difference observed in the +MSU rate, and the incidence in the general population over this period was 7.037%. E. coli was the most common causative organism present in all culture specimens and Klebsiella pneumoniae co-infection in 0.23%. Repeat infection was seen in 11.6% individuals, all of whom were co-infected with HIV/hepatitis C.

Conclusions:

This study represents the largest of its kind in Europe. Females in general are at increased risk regardless of ethnicity. Caucasians are more at increase than non-Caucasians. The hepatitis C and treatment effects are likely driven by a greater proportion of immunocompromised patients having hepatitis C and being on protease inhibitors rather than either the treatment or hepatitis C infection contributing directly.

References

1.Eccles-Radtke C, Rector TS, Cutting A, et al. Urinary tract infections in male veterans with human immunodeficiency virus. Open Forum Infect Dis. 2014;1:ofu100. doi: 10.1093/ofid/ofu100. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S46.

MP-03.13: Angiotensin I-converting enzyme gene polymorphism in Iraqi patients with chronic renal failure

Mohemid Al-Jebouri ¹

Abstract

Introduction and Objectives:

The renin-angiotensin system (RAS) is a key regulator of both blood pressure and kidney functions and their interaction. In such situation, genetic variability in the genes of different components of RAS is likely to contribute for its heterogeneous association in the renal disease patients. Angiotensin-converting enzyme-1 (ACE-1) is an important component of RAS, which determines the vasoactive peptide angiotensin-II.

Methods:

In the present study, we have investigated 100 end-stage renal disease (ESRD) patients and 50 normal healthy controls to deduce the association between ACE gene polymorphism and ESRD. A total of 50 normal healthy controls were also genotyped for ACE I/D polymorphism. The criterion of defining control sample as normal was totally based on the absence of any kidney disease determined from the serum creatinine level. Genotyping of ACE I/D was assayed by polymerase chain reaction (PCR) based DNA amplification using specific flanking primers.

Results:

Of 100 patients with chronic renal failure with different causes, the DD genotype was 56%, II genotype 13%, ID was 28% and negative results was 3%. The control group results was DD 26%, II 26%, ID 22%, and negative results was 26%.

Conclusion:

The results in this study of patients with chronic renal disease indicate that presence of the D allele in the ACE genotype may be of particular importance as a predictor of high rate of progression to ESRD.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S47–S48.

MP-03.14: Isolated hypoxia-induced inflammation and fibrotic pathways in human bladder smooth muscle cells

Bridget Wiafe ¹, Adetola Adesida ¹, Thomas Churchill ¹, Peter Metcalfe ¹

Abstract

Introduction and Objectives:

Several studies have implicated hypoxia in the etiology of partial bladder outlet obstruction (pBOO). However, the isolated effects of hypoxia on bladder cells as far as the initiation and progression of pBOO is concerned are not yet known. Therefore, we aimed to characterize the progressive effects of pure hypoxia on bladder smooth muscle cells.

Methods:

Sub-confluent normal human bladder smooth muscle cells (hbSMC) were cultured in 3% O2 tension for two, 24, 48, and 72 hours. RNA was extracted for gene expression analysis using reverse transcription polymerase chain reaction (RT PCR) and protein produced in culture medium was analysed with enzyme-linked immunsorbant assay (ELISA).

Results:

Transcription of HIF 1 and 2 were transiently induced after two hours of hypoxia (p<0.05) whereas HIF 3 was upregulated after 72 hours (p<0.005). VEGF mRNA increased significantly after 24 and 72 hours (p<0.005). The inflammatory cytokines; TGFB (protein and mRNA), IL 1β, 1L6, and TNFα (mRNA) demonstrated a time-dependent increased expression. Furthermore, the anti-inflammatory cytokine, IL-10, was downregulated after 72 hours (p<0.05). Evidence of myofibroblast activation and EMT included increased αSMA, vimentin, and desmin. Evidence of profibrotic changes included increases in CTGF, SMAD 2 and 3, as well as collagens 1, 2, 3, 4, fibronectin, aggrecan and TIMP 1 transcripts (p<0.05). Total collagen proteins also increased time-dependently (p>0.05).

Conclusions:

Together, these data show that the exposure of hbSMC to low oxygen tension results in intense hypoxic cascade, including inflammation, myofibroblast activation, profibrotic changes, and increased extracellular matrix expression. This elucidates mechanisms of hypoxia-driven bladder deterioration after pBOO and may result in tailored in vivo experiments and, ultimately, translate into improved clinical outcomes.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S47–S48.

MP-03.15: Erythropoietin accelerates the recovery of normal ureteral function following complete unilateral obstruction

Claudia Janssen ^1,², Wolfgang Jäger ^1,², Igor Moskalev ³, Ladan Fazli ³, Joachim Thüroff ², Dirk Lange ¹

Abstract

Introduction and Objectives:

Obstructive uropathy facilitates ureteral aperistalsis and ascending pyelonephritis. While physiologic smooth muscle contractions are lost in the dilated hydroureter during unilateral ureteral obstruction (UUO), the functional recovery of the ureter following obstruction reversal remains unclear. Erythropoietin (EPO) is protective in non-hematopoietic organs and restores peristalsis in hypocontractile intestinal smooth muscle cells. Here, we investigated the role of EPO in the (patho-) physiology of ureteral peristalsis and determined its therapeutic value in obstructive uropathy.

Methods:

Abdominal laparotomy and UUO were performed in female CD-1 mice for 24 hours (Group 1; n=22), 48 hours (Group 2; n=22), or 72 hours (Group 3; n=22) using a non-traumatic vascular micro clip. Expression of EPO, EPO receptor (EPOR), and β-common receptor (βCR) in obstructed and unobstructed ureters was determined via reverse transcription polymerase chain reaction (RT PCR) in group 2 animals. Ten animals per group received 200 IU EPO on four consecutive days; controls received saline. The duration from removal of the obstruction until regression of hydronephrosis was assessed by ultrasonography. Peristaltic activity was tracked microscopically pre- and post-obstruction via open laparatomy.

Results:

Both EPOR and βCR are expressed in murine ureters. Expression of endogenous EPO was remarkably up regulated in obstructed ureters compared to unobstructed ureters in untreated animals. The time until complete resolution of hydronephrosis after removal of the obstruction was found to depend on the duration of obstruction. Despite complete resolution of hydronephrosis after two, six, and eight days (Groups 1, 2, 3), the return of peristalsis was significantly delayed. EPO sigificantly accelerated regression of hydronephrosis and restoration of coordinated ureteral peristalsis in all groups.

Conclusions:

EPO signaling may present a novel target for future therapeutic agents for obstructive uropathy and motility disturbances of the ureter.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S48.

MP-03.16: Urothelial cells express a functional succinate receptor GPR91

Monica Velasquez-Flores ¹, Philippe Cammisotto ¹, Lysanne Campeau ¹

Abstract

Introduction and Objectives:

Lower urinary tract symptoms (LUTS) are associated with the metabolic syndrome (MetS). Increased succinate production is detected in the presence of hyperglycemia and hypoxemia, as with diabetes mellitus and metabolic syndrome, which is strongly associated with overactive bladder syndrome. The aim of our study is to determine how succinate modulated bladder contractility.

Methods:

Urothelial cells were isolated from Sprague-Dawley rat bladder using a collagenase IV method and grown in collagen IV-coated petri dishes. After confluency, cells were exposed to succinate then assessed by microscopy and immunoblotting analysis.

Results:

Immunohistochemistry revealed that cells were confluent and express cytokeratin 17 and the receptor of succinate SUCNR1 (GPR91). Immunohistochemistry confirmed expression of GPR91. Incubation of cells with succinate (10-2 M) results in phosphorylation of Erk and c-Jun amino-terminal kinases (JNKs) JNK, with no effect on Akt-308P, Akt 473P, enos-1177P, or enos-405P. Erk phosphorylation was not observed with exposure to alpha-keto glutarate and citrate, two other intermediates of the citric acid cycle witout affinity to the GPR91 receptor, or malonate, which increases intracellular succinate. On the other hand, succinate dose-dependently decreased the concentrations of intracellular cyclic AMP stimulated by forskolin. Finally, succinate dose-dependently increased the secretion of prostaglandin E2 (PGE2).

Conclusion:

A functional succinate receptor is expressed in urothelial cells. Succinate triggers activation of Erk and JNK by binding to its receptor GPR91, and increasing release of PGE2. These results suggest that succinate might be a major regulator of bladder contractility through its actions on urothelial cell signaling and secretion.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S48–S49.

MP-03.17: A high-throughput minimally invasive murine model for the study of indwelling urinary biomaterial-associated urinary tract infections

Claudia Janssen ^1,², Wolfgang Jäger ^1,², Igor Moskalev ¹, Ben H Chew ¹, Dirk Lange ¹

Abstract

Introduction and Objectives:

Indwelling urinary device-associated infections are one of the most common healthcare-associated infections frequently complicated by encrustation, causing potential blockage of the device. Preclinical research is limited by the lack of relevant high-throughput and cost effective animal models. Current models are restricted to female mice, associated with major transurethral loss of catheter materials during micturition, highly invasive and complex. We present an ultrasound-guided, minimally invasive model enabling the testing of novel antimicrobial biomaterials for indwelling urinary devices in a realistic environment.

Methods:

Implantation of 4 mm catheter segments into murine bladders was performed percutaneously (n=15 males; n=5 females) or transurethrally (n=15 females) using the Seldinger technique under ultrasound guidance. Proteus mirabilis was instilled intraluminally. Catheter encrustation was monitored by ultrasound. Bacteria were quantified from urine and catheters and encrustation analyzed on Days 6 or 21.

Results:

Percutaneous and transurethral catheter implantations were performed efficiently (mean time: 3.6 ± 0.8 min vs. 2.5 ± 0.5 min) in all animals. Ultrasound confirmed that 100% vs. 66%, of implanted catheters remained indwelling over the study period. Catheter encrustation developed in P. mirabilis-infected urine 48 hours post-instillation and its increase over time was detectable with ultrasonography. Fourier Transform Infrared Spectroscopy (FTIR) analysis of the encrustation confirmed a typical struvite spectrum. Control catheters remained sterile over 21 days.

Conclusions:

Our minimally invasive and reproducible percutaneous technique is suitable to study device-associated infection in both genders. Infecting urine with P. mirabilis generates a preclinical model of catheter encrustation within three days. The progression of encrustation can be monitored in vivo using ultrasonography, making this image-based model suitable to assess novel antibacterial and anti-encrustation therapies.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S49.

MP-03.18: Novel antimicrobial peptide coating to prevent catheter-associated urinary tract infections

Joey Lo ¹, Kai Yu ², Evan Haney ³, Claudia Janssen ^1,⁴, Robert E Hancock ³, Jayachandran Kizhakkedathu ², Dirk Lange ¹

Abstract

Introduction and Objectives:

Urinary catheters are ideal surfaces for bacterial biofilm formation, making them the main source of hospital-acquired infections. With the increase in antibiotic resistance, there is a push for non antibiotic-based measures to prevent catheter-associated urinary tract infections (CAUTI). We are pursuing the use of novel antimicrobial catheter coatings using polymer-linked broad-spectrum antimicrobial peptides (AMPs). Here, we present the efficacy of tethered AMPs against common uropathogens in vitro and in a relevant in vivo model.

Methods:

Peptides Tet20, Tet26, and E6 were linked to surfaces at varying densities using polymer brushes PDMA and PSBMA. The antimicrobial activity was determined via colony counts following exposure of uropathogens for up to 48 hours. To evaluate the in vivo efficacy, CAUTI models were developed in mice and rats using 5 mm and 10 mm catheter segments respectively, introduced transurethrally or transcutaneously via ultrasound guidance, followed by transurethral inoculation using 10⁵ S. aureus or P. mirabilis.

Results:

E6-PSBMA and E6-PDMA were shown to be the most effective peptide-brush combinations decreasing the bacterial load up to 10⁸-fold. Tet20-PSBMA and Tet20-PDMA were less effective at up to 100-fold less bacterial load than controls, while all combinations with Tet26 were ineffective. Transcutaneous ultrasound-guided introduction of catheter pieces was more efficient in mice than rats, in which the transurethral method was more successful. Using the transurethral model, coated catheter pieces were found to contain significantly less bacteria compared to uncoated controls.

Conclusions:

Based on our in vitro data, the AMP E6 tethered to surfaces using polymer brushes may be an effective antimicrobial coating to prevent CAUTI. Further testing of these novel coatings using a novel in vivo CAUTI model developed in our laboratory will be important to test the efficacy of these coatings in relevant environments over time.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S50.

MP-04.01: Medication use and survival in diabetic patients with kidney cancer

Madhur Nayan ¹, Erin M Macdonald ², David N Juurlink ^2,³, Peter C Austin ², Antonio Finelli ¹, Girish S Kulkarni ¹, Robert J Hamilton ¹

Abstract

Introduction and Objectives:

Survival rates in kidney cancer have improved little over time, and studies suggest that diabetes is an independent risk factor for poor survival in patients with kidney cancer. The objective of our study was to determine whether medications with putative anti-neoplastic properties (statins, metformin, and non-steroidal anti-inflammatory drugs (NSAIDs)) are associated with improved survival in diabetics with kidney cancer.

Methods:

We conducted a population-based cohort study utilizing linked healthcare databases in Ontario, Canada. We identified patients aged 66 or older with newly diagnosed diabetes and a subsequent diagnosis of incident kidney cancer from 1998 to 2014. Receipt of metformin, statins, or NSAIDs was defined using prescription claims. The primary outcome was all-cause mortality and the secondary outcome was death due to kidney cancer. We used multivariable Cox proportional hazard regression, with medication use modeled with time-varying and cumulative exposure analyses to account for intermittent use.

Results:

During the 14-year study period, we studied 613 patients. Of these, 409 (67%) died, including 194 (32%) from kidney cancer. Current statin use was associated with a markedly reduced risk of death from any cause (adjusted hazard ratio 0.74; 95% CI 0.59–0.91) and death due to kidney cancer (adjusted hazard ratio 0.71; 95% CI 0.51– 0.97). However, survival was not associated with current use of metformin or NSAIDs, or cumulative exposure to any of the medications studied.

Conclusions:

Among diabetic patients with kidney cancer, survival outcomes are associated with active statin use, rather than total cumulative use. These findings support the use of randomized trials to confirm whether diabetics with kidney cancer should be started on a statin at the time of cancer diagnosis to improve survival outcomes.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S50.

MP-04.02: Utilizing fractional polynomials to predict post-chemotherapy retroperitoneal lymph node dissection pathology

Ricardo Leão ¹, Madhur Nayan ¹, Juan Garisto ¹, Kamel Fadaak ¹, Michael A Jewett ¹, Philippe L Bedard ², Padraig Warde ³, Lynn Anson-Cartwright ¹, Peter Chung ³, Joan Sweet ⁴, Martin O’Malley ⁵, Malcom Moore ², Robert J Hamilton ¹

Abstract

Introduction and Objectives:

Post-chemotherapy retroperitoneal lymph node dissection (pcRPLND) is part of the multimodal treatment for patients with advanced germ cell tumours of testis (GCTT). We recommend pcRPLND to all patients with residual masses >1cm. However, in up to 45% of pcRPLNDs, only fibrosis/necrosis is identified. The only validated model (Vergouwe et al) uses six variables with a discriminative ability (c-statistic) of 0.77–0.84, however, has not been adopted clinically. The objective of this study was to construct models with improved discriminative ability and ease of use to predict benign disease.

Methods:

A retrospective review of our pcRPLNDs between 1978 and 2015 was performed. Variables evaluated included pre-chemotherapy orchiectomy pathology, pre-chemotherapy tumour markers, post-chemotherapy mass size, and change in mass size during chemotherapy. Multivariable logistic regression was used to evaluate viable disease (teratoma/cancer) vs. necrosis/fibrosis. Multivariable fractional polynomials (FP) were employed. The models were evaluated for their discriminative ability and reliability (Hosmer-Lemeshow test-HL) A final model was chosen based on parsimony and discriminative ability.

Results:

144 patients were identified. Residual masses contained viable cancer in 16%, teratoma in 57%, necrosis/fibrosis in 27%. Our model, using three variables (teratoma in orchiectomy pathology, pre-chemotherapy AFP, and change in mass size during chemotherapy) had good reliability (HL test p>0.05) and a c-statistic of 0.83. In 102 patients where data to calculate the Vergouwe model was available, our model had a c-statistic of 0.84, while the Vergouwe model had 0.80.

Conclusions:

We developed a three-variable model for the prediction of pcRPLND pathology using FP with comparable performance to the six-variable Vergouwe model. Additional validation in of our model in an independent cohort is required, but if validated, our three-variable model could have more clinical applicability due to ease of use.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S50–S51.

MP-04.03: Validating the Bladder Utility Symptom Scale (BUSS): A novel patient reported quality-of-life instrument for all patients with bladder cancer

Nathan Perlis ¹, Kirstin E Boehme ^1,², Munir A Jamal ³, Karen E Bremner ², Shabbir M Alibhai ⁴, Antonio Finelli ¹, Paul Ritvo ⁵, Murray Krahn ^2,⁶, Rushi Gandhi ¹, Girish S Kulkarni ¹

Abstract

Introduction and Objectives:

Accurately measuring health-related quality of life (HRQOL) is paramount in bladder cancer (BC) care because at each stage patients face diverse treatment modalities with unique morbidities. A patient-reported outcome (PRO) metric validated to measure overall HRQOL for all BC patients does not exist. The purpose of this study was to generate a patient-driven, succinct, global HRQOL questionnaire valid and responsive for BC.

Methods:

Questions were created by a panel of experts based on a conceptual framework of global HRQOL in BC generated through literature review, patient focus groups, and expert interviews. The Bladder Utility Symptoms Scale (BUSS) was pilot tested with experts and patients using cognitive methods until saturation was reached. To determine BUSS-P validation and reliability, field testing was performed at both an academic and community hospital, the University Health Network (Toronto, ON) and Trillium Health Partners (Mississauga, ON), respectively. We used purposive sampling to accrue 117 BC patients. All stages of BC from Ta to metastatic disease were included and patients receiving all forms of treatment were accrued, including intravesical therapy, surgery, radiotherapy, and systemic chemotherapy. Patients completed the BUSS-P and 5 other HRQOL and utility instruments (FACT-Bl, BCI, EQ-5D, SF-36, TTO). Whole and subscale Spearman’s rank correlations (r_s), as well as comparisons of BUSS-P scores across known groups were used to assess construct validity. To assess reliability, patients repeated the questionnaires at four weeks.

Results:

The BUSS contains 10 questions covering both generic and BC-specific domains. In field testing, BUSS exhibited high whole-scale correlation with FACT-Bl (r_s=0.82; p<0.0001) and EQ-5D (r_s=0.67; p<0.0001). Similarly, BUSS-P demonstrated substantial-to-high subscale correlations with EQ-5D (emotional well-being: r_s=0.71; p<0.0001), FACT-Bl (physical well-being: r_s=−0.70; p<0.0001), and BCI (urinary issues: r_s=−0.62; p<0.0001). Median BUSS scores (M) were also significantly different (Kruskal-Wallis, p=0.0016) across patients with differing disease severity: non-muscle invasive BC (M=85.0), cystectomy (M=76.2), and metastatic BC patients (M=66.7). There was excellent test-retest reliability (ICC 0.78). Greater than 95% of respondents completed all BUSS questions, suggesting a comprehensible and well-designed questionnaire.

Conclusions:

These data suggest that the BUSS is a valid PRO to measure HRQOL among BC patients and is useable for patients regardless of treatment exposure, including surgery, radiotherapy, and chemotherapy.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S51.

MP-04.04: Small renal masses: Treatment decision outcomes from a multidisciplinary tumour board

Samir Bidnur ¹, Samrad Ghavimi ¹, Sebastian Frees ¹, Alan I So ¹

Abstract

Introduction and Objectives:

The widespread use of cross-sectional imaging procedures has led to increased diagnoses of small renal masses (SRM). Today, treatment options range from radical nephrectomy (RN) to nephron-sparing surgery (NSS) and local ablative treatments (ABL) to active surveillance (AS). This implicates the need for an interdisciplinary approach in selection of patients’ clinical pathways, such as a multidisciplinary tumour board (MTB). The aim of this study is to evaluate factors influencing decisions made in our MTB and reflect to what extend MTB decisions were followed in the clinical pathway of the individual patient.

Methods:

We identified 85 patients with 100 SMR that were assessed from 2012–2014 in our MTB. Treatment recommendations included ABL for 23, AS for 49, NSS for 24, and RN for four tumours. Several factors influencing treatment decision (tumour size, age of patient, comorbidities, baseline eGFR) were evaluated for each treatment decision group. Final treatment decision at followup was evaluated for each patient and compared to initial MTB recommendation.

Results:

Median followup was 12 months (range 1–37). There was no difference in eGFR between the treatment decision groups. Median age of patients selected for AS (73 years) was significantly higher than age of patients recommended for NSS (66 years) and ABL (65 years) Tumour size was significantly smaller in AS patients (2.2 cm) compared with NSS patients (2.9 cm). Severe comorbidities, multifocality, and previous history of kidney disease were more common in patients selected for AS and NSS. MTB treatment recommendations were followed in 78% of cases. AS was abandoned in 18% for active treatment. Active treatment was changed to AS in 10% of cases (Fig. 1).

Conclusions:

Multiple treatment options exist for the management of SRM. AS patients are generally older, more comorbid patients with smaller masses. Despite the recommendations made by MTB, a significant number of patients will receive an alternative treatment.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S51.

MP-04.05: Achieving the “trifecta” with open vs. minimally invasive partial nephrectomy

Samrad Ghavimi ¹, Olli Saarela ², Ricardo A Rendon ³, Antonio Finelli ², Anil Kapoor ⁴, Ronald B Moore ⁵, Rodney H Breau ⁶, Louis Lacombe ⁷, Jun Kawakami ⁸, Jean-Baptiste Lattouf ⁹, Darrel E Drachenberg ¹⁰, Stephen E Pautler ¹¹, Michael A Jewett ², Liu Zhihui ², Simon Tanguay ¹², Peter C Black ¹

Abstract

Introduction and Objectives:

The “trifecta” summarizes three important outcomes of partial nephrectomy (PN): negative surgical margin, minimal loss of renal function (≤10% decrease in eGFR) and absence of urological complications. Here, we assessed the achievement of the trifecta in patients undergoing open (OPN) vs. laparoscopic (LPN) vs. robotic partial nephrectomy (RPN).

Methods:

From 2000–2014, 865 patients with a first occurrence of a clinical T1 renal mass who underwent OPN (n=405), LPN (n=409), or RPN (n=51) were identified from the Canadian Kidney Cancer Information System (CKCis), a national database. Clinical, surgical, and pathologic parameters were collected and the rate of trifecta, as defined above, was calculated according to surgical approach.

Results:

Pre-operative eGFR was >60 in 81% OPN, 91% LPN, and 94% RPN (p=0.014). The clinical stage was T1a in 59% of OPN, 83% of LPN, and 78% of RPN (p<0.001). Virtually all LPN and RPN cases required warm ischemia, but 61% of OPN used cold ischemia. The mean duration of warm ischemia in those patient who required it was 21.9, 23.7, and 27.8 minutes for OPN, LPN, and RPN, respectively (p=0.13). Negative surgical margins were seen in 385 (95%) OPN, 387 (95%) LPN, and 47 (92%) RPN (p=0.68). A ≤10% change in eGFR was seen in 54%, 54%, and 53% of OPN, LPN, and RPN, respectively (p=0.98). No urological complications were observed in 96% OPN, 92% LPN, and 90% RPN (p=0.014). The overall “trifecta” was achieved in 199 (49%) OPN, 194 (47%) LPN, and 24 (47%) RPN (p=0.876).

Conclusions:

While positive surgical margins and urological complications were uncommon with all three surgical approaches, the postoperative reduction in renal function was the principal obstacle to achieving the trifecta. The trifecta rate was comparable between minimally invasive and open approaches, although the baseline parameters indicate that the lesions undergoing OPN were likely more complex. The analysis is limited by the lack of nephrometry score to correct for the complexity of the surgery.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S52.

MP-04.06: Metformin use does not impact disease-specific mortality among diabetic patients with non-muscle invasive bladder cancer: A population-based analysis

Patrick Richard ¹, Aza Mohammed ¹, Shaheena Bashir ¹, Ricardo Leão ¹, Bimal Bhindi ¹, Neil E Fleshner ¹, Alexandre Zlotta ¹, Girish S Kulkarni ¹

Abstract

Introduction and Objectives:

Non-muscle invasive bladder cancer (NMIBC) is highly prevalent among the elderly. Many bladder cancer (BCa) patients are also afflicted by diabetes mellitus (DM), which affects 25% of persons aged 65 and older. Metformin is a first-line oral therapy used in this population and it has been demonstrated to have some anticancer properties. Our objective was to evaluate the impact of metformin use in NMIBC patients on disease-specific survival (DSS).

Methods:

This is a retrospective, population-based cohort study, in which we used administrative data to identify diabetic patients older than 66 years of age who were subsequently diagnosed with NMIBC in Ontario between 1992 and 2012. Cumulative daily duration of metformin use was calculated before and after the diagnosis of NMIBC. The primary outcome was DSS. A multivariable competing risks model was used to estimate DSS. The model was adjusted for age, year of diagnosis, gender, comorbidity score, and cumulative use of metformin.

Results:

During the study period, 38 383 patients were diagnosed with BCa, of which 10 144 (26%) were also diagnosed with DM. Of these, 2004 subjects older than 66 years of age at the time of DM diagnosis were subsequently diagnosed with de novo NMIBC. 977 (49%) of them were on metformin therapy at some point during followup. After a median followup of 63 months (interquartile range (IQR) 40–93), 1406 (70%) had died, including 367 (18%) deaths from BCa. On multivariable analysis, cumulative duration of metformin use after BCa diagnosis did not appear to impact BCa-specific death in a dose-dependent fashion. The adjusted HR was of 1.06 (95% CI 0.99–1.13) for each additional six months of metformin use.

Conclusions:

In this large, population-based study, we have provided strong evidence that metformin use does not significantly impact DSS among diabetic patients subsequently diagnosed with NMIBC. Given the limitations of the administrative databases, the protective effect of metformin on disease recurrence could not be evaluated and will require further evaluation.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S52.

MP-04.07: Renal function after partial nephrectomy correlates with tumour histology

Shawna Boyle ¹, Michele Fascelli ², Spencer Krane ¹, Marston Linehan ¹, Adam Metwalli ¹

Abstract

Introduction and Objectives:

Partial nephrectomy (PN) is indicated for multifocal and hereditary kidney cancer and preserves renal functional. We present an analysis of postoperative renal function after PN based on tumour histology.

Methods:

A single institution prospectively maintained database of patients undergoing evaluation for renal tumour between 2002 and 2015. Patients who underwent renal surgery with pathologic evaluation and renal function were identified. Only patients with both preoperative nuclear renogram (NRS) and postoperative NRS performed within 12 months of surgery were included. Additional data collected were serum creatinine (Cr), pathology, tumour stage, and demographics. The trends in renal function using Cr and glomerular filtration rate (GFR) for each histologic subtype were observed.

Results:

331 patients, among whom 344 surgeries were performed, were included. The pathologic categories were: clear cell (233), chromophobe (15), hereditary leiomyatosis and renal cell cancer (HLRCC) (3), hybrid oncocytic tumours (28), type 1 papillary (40), and oncocytoma (25). Those patients with papillary tumours had higher Cr and lower GFR (p=0.009) preoperatively; the postoperative decrease in renal function in this pathology was similar to that seen in the other tumour subtypes. Oncocytoma patients also started out with lower GFR (p=0.006); however, unlike other histologies, renal function continued to deteriorate on followup to one year. Postoperative renal function at one year shows a GFR loss for chromophobe and HLRCC that is three times that of clear cell (clear loss 5 ml/min, HLRCC loss 15.7 ml/min, chromophobe loss 15.8 ml/min).

Conclusions:

Renal functional preservation after partial nephrectomy varies based on tumour histology and hereditary kidney cancer condition. Most patients demonstrate stable renal function withinthree months after surgery, but patients with oncocytoma appear to have ongoing loss of renal function over one year followup.

Table 1.

MP-04.07. Renal function by pathologic tumour type

	Clear-cell	Chromophobe	HLRCC	Hybrid onco/chromo	Papillary type 1	Oncocytoma
Cases	233	15	3	28	40	25
Preoperative Cr	0.97 (0.29)	0.86 (0.27)	0.63 (0.22)	0.99 (0.18)	1.11 (0.29)	1.03 (0.29)
6–12-week Cr	1.06 (0.51)	1.02 (0.39)	0.78 (0.19)	1.11 (0.30)	1.24 (0.48)	1.18 (0.34)
1-year Cr	1.06 (0.59)	1.02 (0.34)	0.78 (0.11)	1.08 (0.22)	1.21 (0.46)	1.30 (0.40)
Preoperative GFR	89.7	87.7	117.9	84.0	85.3	75.2
6–12-week GFR	84.4	71.8	102.2	76.5	78.8	66.2
1-year GFR	85.5	75.3	104.3	76.7	80.8	61.3

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S52–S53.

MP-04.08: How to balance the risk of cancer-specific mortality and other-cause mortality in the decision between surgery or observation for patients with T1 kidney cancer

Vincent Trudeau ¹, Alessandro Larcher ^1,², Paolo Dell’Oglio ^1,², Zhe Tian ¹, Nicola Fossati ², Umberto Capitanio ², Alberto Briganti ², Francesco Montorsi ², Pierre Karakiewicz ¹

Abstract

Introduction and Objectives:

Without precise risk assessment of cancer-specific mortality (CSM) and other-cause mortality (OCM) after surgery (SUR) or observation (OBS) for patient with T1 kidney cancer, treatment selection remains an empirical process. The aim of the study was to identify specific patients that would benefit from SUR over OBS.

Methods:

A population-based assessment of 11 192 patients with T1 kidney cancer treated with SUR or OBS in the SEER-Medicare database was performed. SUR was defined as radical or partial nephrectomy. A multivariable competing risk regression model was fitted to predict CSM and OCM after SUR or OBS. Covariates consisted of age, gender, race, Charlson comorbidity index (CCI), history of acute kidney injury (AKI) or chronic kidney disease (CKD), tumour size, and year of diagnosis. Heagerty’s method was used to compute the area under the curve (AUC).

Results:

At a median followup of 64 months the five-year risk of CSM and OCM were 6.7 and 24%, respectively. All the predictors evaluated were associated with the outcomes of interest (p<0.05). According to the proposed model (Fig. 1), the benefit of the choice for SUR over OBS with respect to CSM and OCM was importantly influenced by host and cancer characteristics. The five-year CSM risk of a 70-year-old African-American woman with CCI=0, without AKI or CKD diagnosed with a 65 mm tumour was 14% in case of OBS and 6% in case of SUR. The five-year risk of OCM for the same patient was 12% in case of OBS and 8% in case of SUR. These figures provide strong arguments for selecting SUR over OBS. Conversely, the five-year risk of CSM of an 85-years-old Caucasian man with CCI=8, with AKI or CKD diagnosed with a 15 mm tumour was 8% in case of OBS and 4% in case of SUR. The five-year risk of OCM for the same patient was 74% in case of observation and 58% in case of surgery. These figures provide weaker arguments for selecting SUR over OBS. AUC of the model was 74% for CSM and 73% for OCM.

Conclusions:

The benefit of SUR over OBS resulted maximal in younger and healthier patients with larger tumours and marginal in older and sicker patients with smaller tumours. The proposed model can optimize clinical decision-making, providing crucial and objective information with respect to long-term CSM and OCM risk, which can be used to select elderly patients with T1 kidney cancer for SUR or OBS.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S53.

MP-04.09: Correlation of 18 F-FDG PET/CT findings with histopathological type, grade, and T-stage of renal tumours: A prospective study

Uttam Mete ¹, Rajesh Ghanghas ¹, Ashwani Sood ², Nandita Kakkar ³, Arup Mandal ¹

Abstract

Introduction and Objective:

Contrast-enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) are not 100% accurate for diagnosing histological types, grades, and stage of renal tumour, which play an important role in decision-making while treating these patients. Positron emission tomography (PET)/CT can provide all this informations according to maximum standardized uptake value (SUVmax) of the lesion. This prospective study was done to find any correlation between the SUVmax of 18F-FDG PET/CT with histopathological findings in renal tumour patients.

Methods:

23 patients with solid renal mass underwent FDG PET/CT. SUVmax was automatically calculated by the software for each renal lesion. All patients underwent nephretomy or biopsy of the renal tumour. PET result was correlated with the histopathological parameters.

Result:

Out of 23 patients, 16 had clear-cell renal cell carcinoma (RCC), six non-clear-cell RCC, and one was diagnosed as angiomyolipoma. Five patients had metastatic disease. PET/CT was 95.45 % sensitive and 91.30 % accurate in diagnosing primary lesion, and 100 % sensitive and specific in detecting metastasis. The mean SUVmax of clear-cell RCC lesion was 6.9 (range 1.7–18.3). Increasing SUV max with increasing T-stage was noted. The mean SUVmax of T-stages I, II, III, and IV were 5.05, 3.98, 10.30, and 13.74, respectively. Increased SUVmax with increased Furhman’s grade was also noted (Grade I, II, and III 3.68 (2.11–9.33), 5.0 (3.9–9.35), and 6.6 (4.15–11.33), respectively). Three cases of high-grade urothelial carcinoma and one case of diffuse large B-cell lymphoma had SUVmax >15. One patient had PNET with SUVmax >10.

Conclusions:

The current study establishes the fact that renal lesion can be accurately characterized by PET/CT. The higher SUVmax of the lesion corresponds to high grade and high stage. The majority of the non-clear-cell carcinomas have higher SUVmax compared to clear-cell carcinomas. We propose that PET/CT should be the single most imaging test to be done for evaluation and chacrecterization of renal mass.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S53.

MP-04.10: Short-term morbidity following retroperitoneal lymph node dissection

Nicholas Paterson ¹, Rodney H Breau ^1,², Sonya Cnossen ¹, Joshua Montroy ¹, Ranjeeta Mallick ¹, David Schramm ¹, Dean Fergusson ¹, Ilias Cagiannos ², Christopher G Morash ², Luke T Lavallee ²

Abstract

Introduction and Objectives:

This study evaluated the frequency and timing of complications following retroperitoneal lymph node dissection.

Methods:

Male patients aged 18–50 who received retroperitoneal lymph node dissection (RPLND) with data in The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2006 to 2014 were included. Baseline patient and treatment characteristics were collected. Complications in NSQIP are recorded by trained study nurses through a validated review process. The primary outcome of this study was the incidence of any complication following RPLND. Secondary outcomes included the incidence of individual complications, the timing of complications (in-hospital vs. after discharge) and the association between patient and treatment factors with the occurrence of complications.

Results:

289 patients met inclusion criteria. 39 (13.5%) patients were over 40 years old. The median hospital stay was five days (interquartile range (IQR) 4–7 days). 53 (18.3%) patients experienced at least one postoperative complication. 15 (20%) complications occurred after hospital discharge. The most common complications included: blood transfusion (33; 11.0%), surgical site infection (11; 3.8%), return to the operating room (10; 3.4%), fascial dehiscence (4; 1.4%), deep vein thrombosis (4; 1.4%), and pneumonia (3; 1%). Factors associated with the occurrence of any post-operative complication included: increased age, elevated body mass index, higher American Society of Anesthesiologists class, presence of disseminated cancer, pre-operative weight loss >10% in the previous 6 months, smoking, low serum albumin concentration, pre-operative chemotherapy, and longer operating times (p<0.05).

Conclusions:

18% of RPLND patients experience a perioperative complication. Interventions to reduce blood transfusion should be evaluated.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S54.

MP-04.11: Healthcare services use during the last six months of life among bladder cancer patients who underwent radical cystectomy in Quebec, Canada

Ahmed S Zakaria Ahmed ¹, Fabiano Santos ², Alice Dragomir ¹, Simon Tanguay ¹, Wassim Kassouf ¹, Armen G Aprikian ¹

Abstract

Introduction and Objectives:

Management of bladder cancer imposes a great economic challenge on the healthcare system, with the greatest share of this burden attributed to radical cystectomy (RC) and prolonged followup. Our aim was to characterize healthcare services use and evaluate associated costs predictors during the last six months of life in patients who had RC.

Methods:

We conducted a retrospective study within a cohort of 2988 patients who had RC from 2000–2009. Data was obtained from the RAMQ. We included patients who deceased during the study period and survived at least six months after the first 90 postoperative days. Services billing codes were used to retrieve hospital, outpatient, and imaging services. Linear regression models were used to assess predictors of costs.

Results:

From the 1355 patients who died during the study period, we analyzed data of 799 subjects. Males formed 77.3% and 52% of patients were between 60–75 years. In their last six months of life, 17.2% of patients had surgery for major urinary tract complications; 25% had chemotherapy, while 27.6% had radiotherapy. Also, 3.5% of patients had hemodialysis. Urologist visits ranked first, where 72.3% of patients had 3481 visits (average six visits/patient) followed by medical sub-specialist, where 69% of patients had 10 010 visits (average18 visits/patient). For supportive care, 97% of patients had 25 560 family physician visits (average 31 visits/patient), while only 16% of them had specialized care. Imaging was performed in 94.6% of patients. Services use kept increasing with time, especially during the last two months. Post-RC complications was a significant predictor associated with increased costs at all assessed services (p<0.0001).

Conclusions:

Our study results suggest that healthcare services use varies in the assessed period. Urologists involvement in the process of care tends to decrease in favour of other medical specialties, however, some healthcare services, like specialized supportive care, may be underused.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S54.

MP-04.12: Pathologic evaluation of non-tumour renal tissue predicts renal function post-radical nephrectomy

Adiel E Mamut ¹, Roderick Clark ¹, Gena Abrahim ², Fulan Cui ¹, Neal E Rowe ³, Manal Gabril ², Madeleine Moussa ², Patrick P Luke ¹

Abstract

Introduction and Objectives:

Recent studies have demonstrated that the evaluation of non-neoplastic renal parenchymal tissue post-partial nephrectomy may predict future renal function. We assessed the predictive role of non-neoplastic renal pathology in a cohort of patients with normal preoperative renal function who underwent radical nephrectomy for a renal mass.

Methods:

All local patients with a normal contralateral kidney who underwent radical nephrectomy between April 2002 and May 2008 were identified. Patients with missing clinical data or preoperative chronic kidney disease (CKD), defined as glomerular filtration rate (GFR) <60 mL/min/1.73m²) were excluded. Pathology slides were re-reviewed by a genitourinary pathologist (MM) for presence of glomerulosclerosis (GS), interstitial fibrosis (IF), tubular atrophy (TA), and arterial narrowing (AN), which were correlated with pre- and postoperative renal function. Student’s t-test and logistic regression were used to assess statistical significance.

Results:

97 patients met inclusion criteria and had tissue available for pathology review. GS, IF, TA, and AN was present in 70%, 44%, 44%, and 96% of patients, respectively. The presence of IF and TA was associated with relatively reduced renal function both preoperatively and at one year (p<0.0001). Patients with GS demonstrated significant decline in renal function at one year (p<0.0001) despite normal preoperative renal function. Of the assessed clinical conditions, only hypertension and coronary artery disease were associated with poor postoperative renal function on logistic regression (p=0.04 and 0.04).

Conclusions:

Evaluation of non-tumour renal tissue at the time of radical nephrectomy offers valuable predictive information regarding postoperative renal function. Significant pathological findings were common in our patient cohort. Our data suggest an ongoing role for pathological evaluation of non-neoplastic renal tissue in nephrectomy specimens. The overall impact of pathological evaluation needs to be evaluated in a larger cohort using multivariable analysis.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S54.

MP-04.13: Outcomes of standard vs. off-clamp partial nephrectomies in a porcine model

Daniel Olvera-Posada ¹, Manujendra Saja ^2,³, Ghaleb Aboalsamh ³, David Mikhail ¹, Aaron Haig ⁴, Ian Lobb ^2,³, Jaskirandeep Grewal ^2,³, Alp Sener ^1,^2,³

Abstract

Introduction and Objectives:

Partial nephrectomy (PN) is considered the standard of care for small renal masses. Controversy exists about the real functional benefit regarding off-clamp PN in patients without chronic kidney disease (CKD). We designed a 2/3 total nephrectomy porcine model to assess the underlying mechanisms of ischemia reperfusion injury (IRI) after PN. We evaluated intraoperative parameters, recovery of kidney function, levels of pro-apoptotic, anti-apoptotic and biomarkers of tubular injury.

Methods:

Domestic male pigs (n=13) underwent left lower pole 1/3 PN and allocated to either standard (Group 1: 45 minutes of warm ischemia) or zero ischemia PN using the ALTRUS device (Group 2); followed by contralateral nephrectomy. Biochemical studies were performed at baseline, Day 2 and at Day 7, before sacrifice. PCR and Western blot analyses were used to determine the expression of tissue apoptotic markers. Acute tubular necrosis (ATN) and apoptosis were graded and analyzed by an independent pathologist.

Results:

At Day 2 following PN, there was a significant rise in serum creatinine in Group 1, but not in Group 2 (355 vs. 136 mmol/L, p=0.008), which remained at baseline levels throughout the experiment. Blood hydrogen sulphide (H₂S) levels significantly increased after IRI and returned to baseline levels at Day 7. Intra-renal tissue oxygen saturation after PN inversely correlated with postoperative creatinine (rho −0.75, p=0.012) and grade of ATN (rho −0.70, p=0.036). We observed a rise in expression of pro-apoptotic markers BAD, BAX, and Caspase-3, and pro-inflammatory markers such as EDN1 and NGAL in Group 1 following PN compared to Group 2, which demonstrated no difference from Sham animals (p<0.05). Histological analysis revealed higher grade of ATN and apoptosis in Group 1. Post-PN H₂S blood levels inversely correlated with the grade of apoptosis (rho −0.787, p=0.020), and UPC ratio at Day 7 correlated with ATN (rho 0.866, p=0.003).

Conclusions:

IRI associated with standard PN has a deleterious impact on acute renal function, markers of tissue injury, and histological parameters, including ATN and tissue apoptosis, compared to zero-ischemia PN using the ALTRUS device. We also identified several intraoperative and postoperative imaging and biochemical markers that may be used as predictors for histological injury following PN.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S55.

MP-04.14: Endoscopic removal of inferior vena caval tumour thrombi in patients with renal cell carcinoma: Future perspectives

Mohammed Nouh Ahmed ^1,²

Abstract

Introduction and Objectives:

Removal of inferior vena caval (IVC) tumour thrombi implicates aggressive surgical techniques with high operative morbidity and mortality.¹^,² I represent, herein, a new technique for endoscopic IVC thrombectomy.

Methods:

After isolating the IVC from its infra-renal segment up to right atrium using multichannel catheters; abdominal IVC is dissected free from the posterior abdominal wall. Tumour thrombi are dissected then dragged down to the abdominal IVC using a flexible angioscope (a cystoscope). The abdominal segment is double-clamped and thrombi are removed by irrigation using heparinized saline or through a small cavotomy. In level IV thrombi, right atrium is completely isolated by a double-balloon catheter and thrombi are manipulated as above, guided by a trans-esophageal echocardiogram.

Results:

Untested hypothesis for discussion.

Conclusions:

The above described technique provides a minimally invasive strategy reducing the morbidity and mortality associated with this major surgical challenge and omitting the need for the liver rotation maneuvers or cardiopulmonary bypass and deep hypothermic circulatory arrest.

References

1.Gill IS, Metcalfe C, Abreu A, et al. Robotic level III inferior vena cava tumour thrombectomy: The initial series. J Urol. 2015;194:929–38. doi: 10.1016/j.juro.2015.03.119. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Loh-Doyle J, et al. Vena cavoscopy in the assessment of intraluminal vena caval tumour involvement. AUA. 2015. Abstract PD35-06. [DOI] [PubMed]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S55–S56.

MP-04.15: Hand-assisted laparoscopy infiltrative left radicalnephroureterectomy

I Unal Sert ¹

Abstract

Introduction and Objectives:

Hand-assisted laparoscopy (HAL) combines the advantages of laparoscopy and open surgery. The only difference between standard laparoscopy and HAL is that the surgeons are also able to introduce their hand into the operative field. I would like to present step-by-step my first experience with HAL radical nephrectomy.

Methods:

40-year-old male patient with left renal mass infiltrating to spleen and renal pedicle was admitted to hospital. Hand-assisted radical nephrectomy was recommended to the patient, as classical laparascopic surgery would be difficult to apply. HAL uses all the principles of standard transperitoneal laparoscopy. A pneumoperitoneum is created to insufflate the abdomen. A laparoscope is introduced to provide magnified visualization of the operative field and laparoscopic instruments are used to perform the surgery.The surgeon’s hand is used for exposing, retracting, dissecting, and maintaining hemostasis.

Results:

The total opereative time was 60 minutes. There was no need for transfusion. The patient was dischared from hospital at postoperative Day 3. The scar that the speciemen was removed was 7 cm.

Conclusions:

HAL surgery is a mininmally invasive surgery method that could easily be performed by a urologist trained on traditional open surgery without loss of tactile stimulus. As has been said by Dr. R.V. Clayman, “One hand is worth a thousand trocars.”

References

1.Bannenberg JJG, Meijer DW, Bannenberg JH, et al. Hand-assisted laparoscopic nephrectomy in the pig: Initial report. Minim Invasive Ther Allied Technol. 1996;5:483–7. doi: 10.3109/13645709609153716. [DOI] [Google Scholar]
2.Wolf JS, Jr, Moon TD, Nakada SY. Hand-assisted laparoscopic nephrectomy: Comparison to standard laparoscopic nephrectomy. J Urol. 1998;160:22–7. doi: 10.1016/S0022-5347(01)63016-7. [DOI] [PubMed] [Google Scholar]
3.Slakey DP, Wood JC, Hender D, et al. Laparoscopic living donor nephrectomy: Advantages of the hand-assisted method. Transplantation. 1999;68:581. doi: 10.1097/00007890-199908270-00024. [DOI] [PubMed] [Google Scholar]
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6.Stifelman MD, Sosa RE, Andrade A, et al. Hand-assisted laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper tract. Urology. 2000;56:741–7. doi: 10.1016/S0090-4295(00)00751-2. [DOI] [PubMed] [Google Scholar]
7.Wolf JS, Seifman BD, Montie JE. Nephron-sparing surgery for suspected malignancy: Open surgery compared to laparoscopy with selective use of hand assistance. J Urol. 2000;163:1659–64. doi: 10.1016/S0022-5347(05)67515-5. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S56.

MP-04.16: Survival benefit of supplemental pre-surgical targeted therapy in metastatic renal cell carcinoma patients: A retrospective analysis

Cheng Fang ¹, Anil Kapoor ¹

Abstract

Introduction and Objectives:

Cytoreductive nephrectomy with post-surgical targeted therapy can arguably be regarded as the standard of care for metastatic renal cell carcinoma (RCC). Despite this, the additional role of pre-surgical targeted therapy is uncertain and requires further research. Through retrospective analysis, we seek to compare differences in length of survival between patients who received upfront cytoreductive nephrectomy and post-surgical targeted therapy (adjuvant) to patients who additionally received pre-surgical targeted therapy (combined).

Methods:

Between May 2010 and July 2015, 39 patients with complete patient records who received cytoreductive nephrectomy for metastatic RCC were identified. All 39 patients completed at least one cycle of targeted therapy (sunitinib, pazopanib, and everolimus) over the course of their treatment. Length of survival was calculated from date of nephrectomy and date of CT diagnosis of metastatic disease as separately compared baselines. All patient variables were obtained and recorded from our institution’s database records and patient charts. Statistical analysis was performed with IBM SPSS Statistics 22 software.

Results:

As of March 2016, 20 of the 39 patients have died. Mean length of survival from date of diagnosis to death in the adjuvant therapy cohort was 19.7 months (n=10) compared to 33.7 months in the combined therapy cohort (n=10) for a mean difference of 14 months (p=0.069). Mean length of survival from date of nephrectomy to death in the adjuvant therapy cohort was 17.6 months compared to 24.9 months in the combined therapy cohort for a mean difference of 7.3 months (p=0.297).

Conclusions:

Our retrospective analysis suggests that pre-surgical targeted therapy may confer additional benefits in length of survival, especially from date of diagnosis for metastatic RCC patients. Larger sample size and analysis of the remaining currently alive patients is required to further validate these results.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S56.

MP-04.17: The impact of increasing laparoscopic intra-abdominal pressure and perioperative outcome in nephron-sparing surgery: A critical review

Osama Abusanad ¹, Reymond Mark Evans ¹, Wesam Elbaroni ¹, Harkaren Randhawa ¹, John P Keane ¹, Ali A Thwaini ¹

Abstract

Introduction and Objectives:

Nephron-sparing surgery (NSS) has now become the gold standard treatment of patients with pT1 renal tumours. Adequate haemostasis is essential for advanced laparoscopic surgery. We describe the impact of increasing intra-peritoneal pressure (IAP) on perioperative outcomes.

Methods:

Retrospective data collection for patients who underwent NSS in a single institute between February 2012 and August 2015. Two cohort groups were reviewed according to IAP at the time of off clamp partial nephrectomy, Group A (IAP=12 mmHg), and B (IA=18mmHg). We analyzed on estimated blood loss (EBL), nephrometry score (NS), estimated glomerular filtration rate (eGFR) changes, and length of stay (LOS).

Results:

105 patients underwent laparoscopic NSS. Median age for Groups A and B was 56 (42–76) and 59 (37–75) years, respectively. The last consecutive 40 patients were selected having been performed by a single surgeon in order to minimize the learning curve effect on the outcome. Median EBL for Group A (n=24) was 150 mls and B (n=22) was 250 mls. Average NS for Groups A and B was 1.36 and 6.59, respectively. Median changes of eGFR pre/postoperatively in Groups A and B was 60–55 and 42–42.5, respectively. Median LOS was five and four days for Groups A and B, respectively.

Conclusions:

This study showed that increasing the IAP to 18 mmHg had better outcome regarding changes of eGFR and LOS. The higher EBL could be contributed to more challenging surgery, as demonstrated by increased NS. This concurs with the current literature. However, this needs long-term followup.

References

1.Chiu AW, Azadzoi KM, Hatzichristou DG, et al. Effects of intra-abdominal pressure on renal tissue perfusion during laparoscopy. J Endourol. 1994;8:99–103. doi: 10.1089/end.1994.8.99. [DOI] [PubMed] [Google Scholar]
2.Nishio S, Takeda H, Yokoyama M, et al. Changes in urinary output during laparoscopic adrenalectomy. Br J Urol Intl. 1999;83:944–7. doi: 10.1046/j.1464-410x.1999.00098.x. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S56–S57.

MP-04.18: Zero ischemia time in partial nephrectomy with moderate to high RENAL nephrometry scores

Karen Randhawa ¹, John P Keane ¹, Mark Evans ¹, Wesam Elbaroni ¹, Hugh O’Kane ¹, Ali A Thwaini ¹

Abstract

Introduction and Objectives:

In patients undergoing partial nephrectomy, higher renal nephrometry score has been associated with increased estimated blood loss (EBL), warm ischemia time, and increased hospital stay. We evaluated our experience of zero ischemia time in lesions with higher nephrometry scores.

Methods:

Retrospective imaging and review of partial nephrectomy data at a single institution between April 2003 and August 2015were performed. Perioperative data and tumour complexity using RENAL nephrometry score were collected. Tumours with nephrometry scores of intermediate- and high-complexity were selected. Those with zero ischemia time were compared with those with documented warm ischemia time. Demographic and perioperative data was obtained, and postoperative oncological results and adverse events were analyzed.

Results:

Of 104 patients, 38 were noted to have moderate- and high-complexity nephrometry scores. 32 patients (84.2%) were noted to be of moderate score and six patients (15.8%) were noted to have high scores. 24 patients were noted to have zero ischemia time (Group 1), while the remainder had varying warm ischemia times (Group 2). Although average blood loss reported in our series is higher for Group 1, this is in keeping with zero ischemia and, therefore, as protective of renal function as possible. There is a trend towards higher conversion to open surgery and longer hospital stay for Group 2 with warm ischemia, although this is not considered statistically significant (p=0.32). This could be explained by the learning curve experience with majority of zero ischemia time operations performed later in the series. Positive surgical margin rate was lower in zero ischemia group, demonstrating no potential adverse effect on oncological outcome; there was no statistical significance in EBL between groups (p=0.65).

Conclusions:

Zero ischemia nephron-sparing surgery appears to be an oncologically safe and feasible option in the management of selected complex renal masses.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S58.

MP-05.01: The impact of teaching on the duration of common urological operations

Blayne K Welk ^1,^2,³, Jennifer Winick-Ng ², Andrew McClure ², Chris Vinden ^1,², Sumit Dave ¹, Stephen E Pautler ¹

Abstract

Introduction and Objectives:

Performance-based funding models for hospitals are being introduced in Canada. The ability of teaching hospitals to offer the same level of efficiency as non-teaching hospitals is unknown. Our objective was to compare the operative duration of general urology procedures between teaching and non-teaching hospitals.

Methods:

We used administrative data from the province of Ontario to conduct a retrospective cohort study of all adults who underwent a specified elective urology procedure (2002–2013). Primary outcome was duration of surgical procedure. Primary exposure was the type of hospital (teaching or non-teaching). Negative binomial regression was used for adjusted relative time estimates.

Results:

114 225 procedures were included (midurethral sling=15 707; transurethral prostatectomy=56 066; hydrocele repair=7221; circumcision=12 280; and open radical prostatectomy=22 951). These procedures were performed in a teaching hospital in 21%, 17%, 13%, 15%, and 29% of cases, respectively. The mean operative times for all procedures were higher in teaching centres; the additional operative time ranged from 8.3 minutes (circumcision) to 29.2 minutes (radical prostatectomy). In adjusted analysis (accounting for age, comorbidity, obesity, anesthetic, and surgeon case volume), the patients treated in teaching hospitals continued to have significantly longer procedures (Fig. 1). These results were similar in sensitivity analyses, which adjusted for the potential effect of more complex patients being referred to tertiary centres.

Conclusions:

Five common general urology operations take on average 9–21% longer in teaching hospitals. This may be due to the combined effect of teaching students and residents, or this may be due to inherent systematic inefficiencies within large teaching hospitals. The potential operating room inefficiencies introduced by training future medical professionals should be adjusted for in future hospital funding models.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S58–S59.

MP-05.02: Robotic surgical skill acquisition in trainees: A randomized comparison of the two robotic trainers and trainees’ skills transfer to a 3D printed simulated surgical task in the operating room

Nathan C Wong ¹, Jen Hoogenes ¹, Badr Alharbi ¹, Saahil Vij ¹, Kevin Kim ¹, Elisa Bolognone ¹, Bobby Shayegan ¹, Mackenzie A Quantz ², Edward D Matsumoto ¹

Abstract

Introduction and Objectives:

With competency-based education on the horizon, there is a growing need for objective methods for evaluating technical ability. The dV-Trainer (dVT) and the da Vinci Surgical Skills Simulator (dVSSS) are virtual reality robotic simulators that use the same software and objective metrics. We aimed to determine how skills acquired on these two simulators transfer to performing an urethrovesical anastomosis (UVA) on a high-fidelity 3D printed bladder model in the OR using the da Vinci robot.

Methods:

Medical students (MS) and junior residents (JR) were recruited through program directors via email. Participants were randomized to training sessions on either the dVT or dVSSS. All participants completed the identical curriculum. They watched a video of a live UVA and subsequently performed it on the high-fidelity model. Pre- and post-training surveys were collected. Scores (/100) were obtained from the software and three robotic surgeons independently evaluated videos and final end product of the UVA in accordance to previously validated scoring systems (GEARS (/25) and RACE (/25)). All analysts and evaluators were blinded.

Results:

A total of 26 participants (11 MS and 15 JR) were recruited and randomized to the dVT and dVSSS. Mean age was 25.5 and 53.8% were females. The average scores for the dVT and dVSSS were 10 and 48.5/100 respectively. Scores of MS and JR were similar (p=0.36). Both GEARS and RACE scores of participants who used the dVSSS compared to the dVT were significantly higher (GEARS: 21/25 vs. 17.2/25, p=0.04; RACE: 23.2/25 vs. 17.8/25, p=0.02). Scores of MS and JR were similar for GEARS (p=0.50) and RACE scores (p=0.57). Intraclass correlation coefficient for the GEARS and RACE scoring were 72.6 and 89.3, respectively.

Conclusions:

The dVSSS lead to superior scores in performing UVA in the OR for both MS and JR compared to the dVT. The dVSSS can be used to improve teaching in surgical trainees in a safe and effective manner.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S58.

MP-05.03: Trends in the training of female urology residents in Canada

Kate Anderson ¹, Karthik Tennankore ², Ashley R Cox ¹

Abstract

Introduction and Objectives:

With the increasing proportion of females graduating from Canadian medical schools, many surgical subspecialties have seen an increase in female trainees. To date, there is limited research on why females do or do not choose a career in urology. The objective of this study was to assess for secular trends in the proportion and success of Canadian female urology applicants.

Methods:

In this descriptive study, publically available data from the Canadian Residency Matching Service (CaRMS) website was collected. Information regarding the number of urology spots, total number of first choice applicants, and total number of applicants successfully matched to urology as a first choice was collected. Trends in the proportion of female applicants who ranked urology as their first choice and who successfully matched to urology as their first choice were also compared to trends in the overall proportions of females entering the CaRMS match and those applying to surgical specialties overall. Data was analyzed using a Chi-square test for trends in proportions.

Results:

Available CaRMS data was complete from 1998–2015. We found a large amount of year-to-year variation in the data. Therefore, data was analyzed based on four-year increments, representing medical school cohorts. We found an increasing trend in the number of female CaRMS applicants overall (p<0.001), in the number of females ranking a surgical program as first choice (p<0.001), and in the number of females successfully matching to a surgical program (p<0.001). With respect to urology, we found a trend towards an increasing number of females ranking urology as their first choice program (p=0.04), but statistically, we did not confirm a trend towards an increasing number of females successfully matching to urology as their first choice program (p=0.07). Despite the lack of statistical significance, the graphical representation of this data did show a positive trend, which mirrors the trends seen in surgical programs overall.

Conclusions:

Over the last 18 years in Canada, more females medical students are applying to urology, which may reflect the overall increase in the number of female applicants within the CaRMS match and mirrors what is seen in surgical programs overall. Similar to surgical programs overall, there also appears to be an increase in the number of females who are successful in matching to urology as their first choice specialty.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S59–S60.

MP-05.04: Risk of venous thromboembolism after urological procedures

Kristen McAlpine ^1,^2,³, Rodney H Breau ^1,^2,^3,⁴, Ranjeeta Mallick ⁴, Sonya Cnossen ⁴, Ilias Cagiannos ^1,^2,^3,⁴, Christopher G Morash ^1,^2,^3,⁴, Luke T Lavallee ^1,^2,^3,⁴

Abstract

Introduction and Objectives:

Venous thromboembolism (VTE) is an important cause of morbidity and mortality following urological procedures. Determining the rate and timing of VTE for individual procedures will improve patient counselling and allow an evidence-based application of VTE prophylaxis strategies.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed from 2006–2014. Current procedural terminology (CPT) codes for similar surgical procedures were grouped together. Baseline patient characteristics were recorded. The primary outcome was the incidence of VTE. Secondary outcomes included the overall incidence of VTE for all patients and the timing of VTE (in-hospital vs. out-of hospital). Absolute rates of VTE and VTE rates out-of-hospital were ranked by procedure type.

Results:

We reviewed 137 968 patients who had a urological procedure. The overall risk of VTE in all patients was 0.9%. The highest incidence of VTE occurred with radical cystectomy (5.0%), open radical nephrectomy (2.2%), open adrenalectomy (2.1%), partial cystectomy (1.9%), and open nephroureterectomy (1.9%) (Table 1). Among the 10 highest VTE risk procedures, 47% of VTEs occurred after discharge from hospital. Over 50% of patients receiving these procedures had multiple risk factors for VTE, including age >60 years, body mass index >25, and operative time >45 minutes.

Conclusions:

Risk factors for VTE, including advanced age, presence of malignancy, elevated body mass index, and receipt of major surgery, are common for urology patients. Risk of VTE varies by surgical procedure, therefore, strategies for VTE prophylaxis should be tailored to procedure risk.

Table 1.

MP-05.04. Incidence of VTE after urological surgery

Rank	Procedure	n	VTE overall (%)	% of VTE occurring after discharge
1	Cystectomy	5973	5.0	50
2	Open nephrectomy	5586	2.2	31
3	Adrenalectomy	390	2.1	37
4	Partial cystectomy	524	1.9	48
5	Suprapubic prostatectomy	525	1.9	90
6	Open nephroureterectomy	678	1.9	54
7	Ureteric reimplantation	217	1.8	50
8	Penectomy	67	1.5	12
9	Laparoscopic nephroureterectomy	1681	1.5	48
10	Open partial nephrectomy	4007	1.1	58

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S60.

MP-05.05: International survey on use of thromboprophylaxis in urological surgery (ISTHMUS)

Philippe D Violette ¹, Arnav Agarwal ^2,³, Yoshitaka Aoki ⁴, Rufus Cartwright ^5,⁶, Giacomo Novara ⁷, Thomas Tailly ¹, Yoichi Arai ⁸, Samantha Craigie ^2,⁹, Gordon H Guyatt ^2,¹⁰, Kari AO Tikkinen ^11,¹²

Abstract

Introduction and Objectives:

The use of thromboprophylaxis to reduce the risk of venous thromboembolism (VTE) in urological surgery is common, but not standardized. We have conducted an international survey to assess current practice variation globally.

Methods:

We developed a survey addressing the use of mechanical and pharmacological thromboprophylaxis for three common urological procedures: cystectomy (Cx), radical prostatectomy (RP), and nephrectomy (Nx). The survey presented three brief patient profiles that reflected a spectrum of VTE risk; respondents indicated their practice for each. Following pilot testing, we administered the survey to representative samples of urologists in Canada, Finland, and Japan. Within-country and between-country variation are described using counts and percents with Chi-square and ANOVA analysis where appropriate. Multivariable logistic regression was used to identify characteristics associated with discharge pharmacological prophylaxis.

Results:

We received a total of 570 eligible responses (Canada 216 of 382, 56.5%; Finland 109 of 179, 60.9%; and Japan 244 of 487, 50.1%). Large between-country variation was observed in pharmacologic prophylaxis for each procedure. Urologists in Finland were most likely to prescribe prophylaxis post-discharge (95% Cx, 75% RP, 72% Nx) as compared to Canada (39% Cx, 15% RP, 10% Nx) and Japan (8% Cx, 1% RP, 1% Nx); p<0.001 across countries for each procedure. Less variation was present for mechanical prophylaxis, which was most commonly used until ambulation or discharge. Residents were more likely to prescribe pharmacological prophylaxis at discharge compared to attending urologists, odds ratios Cx 2.3 (1.3, 4.0), RP 2.3 (1.1, 4.7), Nx 2.2 (0.9, 4.9) after adjusting for country.

Conclusions:

We found very large variation in use of post-discharge pharmacological thromboprophylaxis between countries. This practice variation mandates action to produce procedure-specific clinical practice guidelines.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S60.

MP-05.06: Crowd-sourced assessment of technical skills for validation of basic laparoscopic urological skills (BLUS) tasks

Elspeth M McDougall ^1,², Timothy Kowalewski ², Bryan Comstock ², Robert Sweet ², Cory Schaffhausen ², Ashleigh Menhadji ², Timothy Averch ², Geoffrey Box ², Timothy Brand ², Michael Ferrandino ², Jihad Kaouk ², Bodo E Knudsen ², Jaime Landman ², Benjamin Lee ², Bradley Schwartz ², Thomas Lendvay ²

Abstract

Introduction and Objectives:

The American Urological Association (AUA) sought to pursue a “basic” laparoscopic training and credentialing initiative called Basic Laparoscopic Urological Skills (BLUS) to address both cognitive and technical skills as appropriate to urological laparoscopy. The BLUS consortium sought to address the problem of accurate, scalable, and affordable skill evaluation by investigating the concordance of two novel assessment methods with faculty panel scores: automated motion metrics (EDGE device, Simulab Corp., Seattle WA) and crowdsourcing (C-SATS Inc., Seattle WA).

Methods:

A faculty panel of surgeons (n=5) and anonymous crowdworkers blindly reviewed a randomized sequence of a representative sample of videos (n=24, 12 pegboard and 12 suturing) extracted from the BLUS validation study (n=454) using the GOALS survey tool with appended pass/fail anchors via the same web-based user interface. Pre-recorded motion metrics (tool path length, jerk cost, etc.) were available for each video. Cronbach’s alpha, Pearson’s R, and receiver operator curves (ROC) with area under curve (AUC) statistics were used to evaluate concordance between continuous scores and pass/fail criteria among the three groups: faculty, crowds, and motion metrics.

Results:

Crowdworkers provided 1840 ratings in approximately 48 hours, 60 times faster than the faculty panel. The inter-rater reliability of mean expert and crowd ratings was good (p=0.826). Crowd-score derived pass/fail resulted in 96.9% AUC (95% CI 90.3–100%; 100%PPV, 89%NPV). Motion metrics and crowd scores provided very similar or nearly identical concordance with faculty panel ratings and pass/fail decisions.

Conclusions:

The overall agreement between faculty, motion metrics, and crowdworkers further supports the construct validity of the BLUS tasks. Further investigation of crowdworker assessment of surgeon video-recorded skill proficiency alongside automated motion metrics is warranted.

American Urological Association provided funding for this research

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S60–S61.

MP-05.07: Setting national standards in basic laparoscopic skills for Canadian urology trainees

Jason Y Lee ¹, Sero Andonian ², Kenneth T Pace ¹, Ethan D Grober ¹

Abstract

Introduction and Objectives:

As Canadian residency programs move to a competency-based training (CBT) model, iterative assessments against an objective set of standards will be necessary. To develop a valid set of technical skills standards for Canadian urology trainees, we initiated a national skills assessment study focusing initially on basic laparoscopic skills.

Methods:

Between February 2014 and October 2015, the basic laparoscopic skills of Canadian urology trainees were assessed. Residents at different stages of training completed four standardized tasks (peg transfer, pattern cutting, suturing and knot-tying, clip applying) from the validated Basic Laparoscopic Urological Skills (BLUS) curriculum. Staff urologists were also tested. All performances were video-recorded. Performances were assessed using two different methods: traditional time plus errors-based (TE) scoring and global rating scores (GOALS) using a novel crowd-sourcing platform (CSATS). Contrasting groups method was used for standard setting.

Results:

A total of 99 urology trainees (47PGY0, 15 PGY3, 37 PGY5) and six staff urologists completed the testing. Reported clinical lap experience and level of training both correlated with performance scores on all four tasks (p<0.01). Staff performance, using both TE and GOALS scoring methods, was significantly different from any level trainee on all four tasks (p<0.05; Table 1). Reported access to lap skills training tools correlated with trainee performance scores. Using staff urologist scores, various accepted passing scores can be selected for trainees at any level for standard setting purposes (Table 2).

Conclusions:

The four validated BLUS tasks demonstrated construct validity evidence for the purpose of assessing the basic laparoscopic skills of Canadian urology trainees. Based on a large cohort of trainees, mean performance scores on these four BLUS tasks have been established at three different levels of training and for faculty urologists, which can now be used to set standards.

Table 1.

MP-05.07.

Mean task scores	PGY0 (n=47)	PGY3 (n=15)	PGY5 (n=25)	Faculty (n=5)	p value
Peg-transfer
TE score (max 300)	166.1 ± 58.4	127.0 ± 44.8	100.0 ± 29.4	58.0 ± 6.2	<0.01
GOALS score (max 20)	12.1 ± 2.0	13.3 ± 1.2	13.9 ± 1.9	15.8 ± 1.1	<0.01
Pattern cutting
TE score (max 300)	292.2 ± 22.8	260.8 ± 69.0	204.1 ± 50.0	103.2 ± 18.3	<0.01
GOALS score (max 20)	10.4 ±1 .5	11.4 ± 1.7	12.8 ± 1.5	14.4 ± 1.0	<0.01
Suturing and knot-tying
TE score (max 300)	290.6 ± 28.3	176.9 ± 84.1	135.3 ± 37.1	58.5 ± 6.4	<0.01
GOALS score (max 20)	10.6 ± 1.5	13.6 ± 2.0	13.7 ± 1.5	16.5 ± 1.1	<0.01
Clip-applying
TE score (max 90)	71.0 ± 17.1	64.6 ± 21.1	46.2 ± 16.5	22.8 ± 2.0	<0.01
GOALS score (max 20)	12.8 ± 1.1	13.5 ± 1.4	14.4 ± 2.0	16.5 ±1 .5	<0.01

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Table 2.

MP-05.07.

	% within 1 SD of faculty pegtransfer task (TE score)	% within 1 SD of faculty Pattern-cut task (TE score)	% within 1 SD of faculty suturing task (TE score)	% within 1 SD of faculty clip-applying task (TE score)
PGY0	8.5%
PGY3	20.0%
PGY5	32.4%

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Footnotes

This study was funded by CUA Scholarship Fund

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S61.

MP-05.08: Assessment of endourology simulator use in Canadian training programs

Andrew Rasmussen ¹, Keith F Rourke ¹

Abstract

Introduction and Objectives:

With the dawn of competency-based resident education, there will likely be an emerging need for surgical simulation to fill gaps in resident surgical skill acquisition and evaluation. While there are numerous validated endourology simulators reported, there is a lack of formal data describing their use in Canadian residency training programs. The objective of this study is to describe the use of and attitudes towards endourology simulators in Canada.

Methods:

Two web-based surveys were distributed; the first to the Royal College Urology Specialty Committee (RC) and the second to Canadian Urological Association (CUA) general membership (GM). The surveys collected numeric, categorical, and free-text responses. Major themes included demographics, resident simulator usage patterns, attitudes towards simulators, and perceived barriers to their use. Data were analyzed using a mixed methods approach.

Results:

17 participants responded to the RC survey and 67 responded to the GM survey. 85% (11/13) residency programs were represented in the RC survey. 94% of RC participants were academic urologists, while the GM group was more heterogeneous (52% academic vs. 48% clinical/community-based). 64% of the represented programs reported use of endourology simulators, while 57% of those programs used simulators as part of the formal skills curriculum. Only 6% use simulation regularly (monthly or more) while 12% use simulation for routine evaluation. 82% of RC survey participants and 64% of GM participants agreed that simulators are useful in resident education, particularly in the PGY 1–3 group. Barriers to simulator use were varied, but cost and lack of faculty interest were cited most frequently in both groups.

Conclusions:

While numerous barriers to implementation exist and are not used, simulators are used intermittently across Canada and are viewed favourably by most. Both literature and opinion suggest that simulation is most effectively used in the junior resident population.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S61–S62.

MP-05.09: Age-stratified perioperative mortality after urological surgeries

Brendan Wallace ¹, Rodney H Breau ¹, Ranjeeta Mallick ¹, Sonya Cnossen ¹, Ilias Cagiannos ¹, Christopher G Morash ¹, Luke T Lavallee ¹

Abstract

Introduction and Objectives:

Many elderly patients receive urological surgery. Understanding the risk of death after urological surgery is important for patient selection and counselling.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed from 2006–2014. Current procedural terminology (CPT) codes for similar surgical procedures were grouped for analysis. Commonly performed urological procedures were identified and stratified by patient age and surgical approach (open vs. laparoscopic/robotic). The primary outcome was the absolute risk of death by 30 days stratified by age for each surgical procedure. Secondary outcomes were relative risk of death by age group, death in-hospital vs. after discharge, and risk of death by surgical approach (open vs. laparoscopic/robotic).

Results:

12 urological procedures and 93 719 patients were reviewed. 36% of patients receiving surgery were over age 70 and 12% were over age 80. A total of 765 (0.8%) deaths occurred in patients receiving these procedures by 30 days after surgery. The procedure with the highest incidence of death by 30 days was open nephroureterectomy (3.2%). In patients over 80, the procedure with the highest incidence of death was open nephrectomy (6.0%). The incidence of death increased by age group for all procedures. The risk of death is consistently increased in patients who receive open compared to laparoscopic surgery.

Conclusions:

Knowledge regarding the absolute risk of death in patients receiving common urological surgeries improves patient selection and counselling. As anticipated, the risk of death consistently increases by age group for all urological procedures.

Table 1.

MP-05.09. Death within 30 days of surgery stratified by age.

Procedure	n	Overall	<50	50–59	60–69	70–79	≥80
Open nephroureterectomy	678	3.2%	1.2%	1.2%	2.5%	5.2%	4.2%
Radical cystectomy with diversion	5994	2.4%	1.1%	1.3%	1.6%	2.8%	4.9%
Percutaneous nephrolithotomy	144	2.1%	0.0%	2.1%	0.0%	^*	^*
Open radical nephrectomy	5577	1.8%	0.9%	1.2%	1.3%	2.9%	6.0%
TURBT	11 849	1.7%	0.9%	1.1%	0.6%	1.2%	3.5%
Lap nephroureterectomy	1681	1.3%	0.0%	0.9%	1.7%	1.0%	2.2%
TURP	18 494	0.7%	0.0%	0.2%	0.3%	0.5%	1.8%
Lap radical nephrectomy	8534	0.6%	0.0%	0.4%	0.5%	0.7%	2.0%
Open partial nephrectomy	4007	0.6%	0.1%	0.2%	0.5%	1.0%	4.6%
Lap partial nephrectomy	6558	0.3%	0.1%	0.1%	0.2%	0.7%	2.1%
Open radical prostatectomy	6202	0.2%	0.0%	0.1%	0.2%	0.5%	1.1%
Lap/robotic prostatectomy	24 001	0.1%	0.0%	0.1%	0.1%	0.2%	2.4%

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Lap: laparoscopic

^*

Incidences for procedures with less than 20 cases per age group not reported.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S62.

MP-05.10: Impact of a training program on graduating residents’ performance on a national preparatory exam for certification in the specialty of urology: Results of the last 13 consecutive years

Naji J Touma ¹, Darren T Beiko ¹, Michael J Leveridge ¹

Abstract

Introduction and Objectives:

The performance of graduating residents on certification exams is likely impacted by many factors. It is unknown, however, whether a training program has any impact on the performance of its graduates on certification exams. We present 13 years of results of a national preparatory exam that all graduating residents complete about three months before the RCPSC exam. The aim of this study is to analyze the impact of a training program on the performance of its residents and identify any trends over time.

Methods:

A retrospective review of the exam results from 2003–2015 was conducted. During that time, 378 candidates from all 12 Canadian urology training programs undertook the exam. The performances of graduating residents from each individual program were grouped together for any given year. The different programs were anonomized as the aim of this study is to assess the impact of a training program and not to rate the different programs. Statistical analysis using one-way ANOVA was conducted.

Results:

The means for the written component, oral component, and overall score are 73.79%, 74.16%, and 73.97% respectively. All training programs fall within one standard deviation from the mean for the written component, the oral component, and the overall score. The residents of four training programs had statistically better scores than the overall mean of the written component. The residents of three out of these four training programs also had statistically better scores than the overall mean of the oral component and the overall results of the exam. No training program produced mean exam scores that are statistically worse than the overall mean in any component of the exam or in the overall score.

Conclusions:

Most Canadian training programs prepare their residents adequately for the certification exam in urology. However, there are some training programs that consistently prepare graduating residents to outperform their peers.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S62–S63.

MP-05.11: Series of systematic reviews and meta-analyses of the risk of thrombosis and bleeding in urological cancer surgery (ROTBUS Cancer)

Philippe D Violette ¹, Samantha Craigie ^2,³, Arnav Agarwal ^2,⁴, Giacomo Novara ⁵, Rufus Cartwright ^6,⁷, Richard Naspro ⁸, Reed A Siemieniuk ⁹, Michael K Gould ¹⁰, Per Morten Sandset ^11,¹², Gordon H Guyatt ^2,¹³, Kari AO Tikkinen ^14,¹⁵

Abstract

Introduction and Objectives:

Pharmacological thromboprophylaxis involves trading off reduction in venous thromboembolism (VTE) against increased bleeding. Here, we provide best estimates of absolute risk of VTE and bleeding in urological cancer surgery.

Methods:

We searched for contemporary observational studies reporting symptomatic VTE or bleeding after urological procedures. For each procedure, we accounted for use of thromboprophylaxis and length of followup, and derived best estimates from the median of included studies. Primary endpoints were four-week postoperative incidence of symptomatic VTE and bleeding requiring re-operation. We stratified on patient risk factors for VTE (body mass index (BMI) >35, age >75, personal or family history). Quality of evidence was assessed using GRADE.

Results:

We included 64 studies reporting on 13 urological cancer procedures, including different approaches of cystectomy, prostatectomy, and nephrectomy. Quality of evidence was moderate for prostatectomy and cystectomy and low or very low for renal procedures. Risk of VTE varied widely between procedures, and between approaches within the same procedure. Cystectomies were high risk for VTE (rang 2.9–13.9%), but low-risk for bleeding (0.3%). Risks of VTE in prostatectomies showed substantial variation depending on patient risk factors and use of pelvic lymph nodes dissection (PLND) (0.2–15.7%), with bleeding risks from 0.2–0.4%. VTE risks in renal cancer surgeries were 0.7–6.2% across patient risk groups, with bleeding risks of 0.1–1.7%.

Conclusions:

Our results suggest that extended thromboprophylaxis is clearly warranted in some procedures. For those operations where the tradeoff is less clear, the decision will depend on surgeon and patient values and preferences with regard to VTE and bleeding.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S63.

UP-05.01: The effect of an automated appointment reminder service on non-attendance rates in a high-volume urology centre

Ian TS Wright ¹, Trafford Crump ¹, Richard J Baverstock ¹

Abstract

Introduction and Objectives:

Non-attendance reduces the efficiency of healthcare delivery, increasing the length of wait lists and costs. Automated appointment reminder services (AARS) are an alternative to live telephone reminders. Here we examine the effect of an AARS on non-attendance rates for outpatient procedure and clinic appointments at a high-volume urology centre.

Methods:

An AARS was implemented at our high-volume urology centre on August 1, 2015. Patients were contacted by telephone one week prior to scheduled appointment with an automated reminder of the appointment date and time and an option to confirm or cancel the appointment via numerical selection. Electronic medical record data was retrospectively reviewed for outpatient office and ambulatory cystoscopy appointments before and after implementation. AARS call status, patient age, sex, referral diagnosis, visit type, and time from last encounter to appointment date were collected. Non-attendance was defined as the patient cancelling the visit <24 hours prior to time of appointment or not arriving for the appointment. Data was compared to determine the effectiveness of the AARS on reducing non-attendance rates.

Results:

460 patient charts were reviewed; 228 prior to and 242 after the implementation of the AARS. Of the 242 patients evaluated after implementation of the AARS, 130 were successfully contacted. The nonattendance rate for patients contacted by the AARS was 10.7% compared to 7.6% for those not notified by the AARS (p=0.27). Patient age, sex, referring diagnosis, visit type, and time from last encounter to appointment date were balanced between non-attendees and attendees. One patient cancelled his/her appointment via the AARS.

Conclusions:

The use of an AARS made no difference to the non-attendance rates for outpatient office and cystoscopy appointments. In our real-world experience with this AARS, only 54% of the patients scheduled for appointments were contacted successfully.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S63.

UP-05.02: Longitudinal results of a national preparatory exam for certification in the specialty of urology: Strengths and weaknesses of graduating residents over the last 13 years

Naji J Touma ¹, Darren T Beiko ¹, Michael J Leveridge ¹

Abstract

Introduction and Objectives:

Certification by the Royal College of Physicians and Surgeons of Canada (RCPSC) into the specialty of urology requires the completion of a five-year residency at an accredited institution and the successful sitting of a comprehensive exam at the end of residency. The content and the results of this certifying exam are not disclosed beyond a pass or fail result. We present 13 years of results of a national preparatory exam that all graduating residents complete about three months before the RCPSC exam. This exam, known colloquially as QUEST, aims to simulate the RCPSC exam with written and oral components. The aim of the study was to assess the level of knowledge of graduating urology residents and whether any gaps can be identified in any aspect of urological training.

Methods:

A retrospective review of the exam results from 2003–2015 was conducted. During that time, 378 candidates from all 12 Canadian urology training programs undertook the exam. The exam contents were divided into 10 different topics to ascertain differences in knowledge. The broad categories included oncology, pediatrics, endourology, andrology, female urology, benign conditions, communication, urodynamics, imaging, and visual recognition. Statistical analysis using one-way ANOVA was conducted.

Results:

There is a direct linear correlation between performance on the written and the oral components of the exam. Candidates perform equally well on topics related to oncology (mean=76.8%), pediatrics (mean=79.5%), endourology (mean=76.2%), andrology (mean=78.6%), female urology (mean=78.2%), benign conditions (mean=78.7%), and communication (mean=75.6%). However, components of the exam related to interpretation of urodynamics (mean=63.4%), imaging (mean=67.1%), and visual recognition (mean=65.8%) seem to result in lower marks.

Conclusions:

Graduating residents seem to underperform on interpretative components of a preparatory exam for certification. Those components include urodynamics, imaging, and visual recognition.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S63.

UP-05.03: Using a web-based decision support program to facilitate urological treatment discussions with men newly diagnosed with prostate cancer

Barbara Davison ¹, Michael Szafron ², Kishore Visvanathan ³, Mustafa Andkhoie ²

Abstract

Introduction and Objectives:

To measure the impact of using a web-based decision support technology, the Decision Support Intervention-Prostate Cancer (DSI-PC), to facilitate treatment consultations of men newly diagnosed with prostate cancer (PC).

Methods:

Health information seeking behaviour, factors having an influence on the treatment decision, decision control, and preferred treatment prior to making a treatment decision were recorded by the DSI-PC program. A summary page of responses was provided to patients to use at treatment discussions. Measures of decision control and decision conflict were measured prior to the medical treatment consultation and following a treatment decision. Patient satisfaction was measured after a treatment decision had been made.

Results:

49 men completed the DSI-PC program prior to their treatment consultation. 61% of patients shared the summary sheet with a physician who was involved in their care and 47% discussed the summary sheet with a nurse educator. Impact of treatment on survival was the main factor having an influence on treatment choice. Levels of decisional conflict were significantly lower (p<0.001) following the treatment decision, and men reported assuming a significantly more active role in treatment decision-making (TDM) (p=0.038) compared to initial assessment. Patients reported high levels of satisfaction with their involvement in medical decision-making and the information they received to participate in TDM.

Conclusions:

Results suggest the DSI-PC intervention provides a unique way for urologists and other healthcare professionals to tailor the type and amount of information patients need to make an informed treatment decision.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S63–S64.

UP-05.04: An investigation of the quality of radical and partial nephrectomy educational videos on YouTube

Jas Singh ¹, Premal Patel ¹, Thomas B McGregor ¹

Abstract

Introduction and Objectives:

The Internet is a widely available source of health information for clinicians and patients. Many patients preparing to undergo surgery often look to the Internet for information.¹ YouTube is a popular source for videos and is, therefore, a common starting place for patients. The aim of this study is to assess the quality of videos on YouTube relating to radical and partial nephrectomy.

Methods:

A search was performed on the website YouTube, which included the search terms,“laparoscopic radical nephrectomy”(LRN), “laparoscopic partial nephrectomy”(LPN), “open radical nephrectomy”(ORN), and “open partial nephrectomy”(OPN). The first 50 videos were reviewed and included if they did not meet exclusion criteria, such as non-English language, non-human animal, specific surgical technique, interviews, academic presentations, hand/robotic assistance. Videos were independently reviewed by two urologists and two urology residents. In total, 69 videos met inclusion and five were chosen randomly from each category and reviewed. All videos were evaluated using a five-point Likert scale with a score of 1 indicating poor quality and 5 indicating excellent quality. Videos were assessed based on surgical demonstration, patient applicability, surgical outcomes, and overall assessment.

Results:

The LRN, LPN, ORN, and OPN, mean scores for surgical demonstration were 3.2, 2.65, 3.02, and 3.58, respectively. For patient applicability, they were 1.87, 2.00, 1.47, and 3.00, respectively; and for surgical outcomes, they were 1.23, 1.00, 1.00, and 1.70, respectively. The overall assessment scores were 2.8, 2.53, 1.3, and 2.45, respectively. A direct comparison between resident and urologist scores did not appear to demonstrate a statistically significant difference (p=0.949).

Conclusions:

The quality of educational videos involving radical and partial nephrectomy on YouTube is quite variable. While a number of high-quality videos exist, there is poor consistency and the majority of content is either poorly demonstrated or highly uninformative.

References

1.McMullan M. Patients using the Internet to obtain health information: How this affects the patient–health professional relationship. Patient Educ Couns. 2006;63:24–8. doi: 10.1016/j.pec.2005.10.006. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S64.

UP-05.05: The landscape of systematic reviews in urology (1998–2015): An assessment of methodological quality

Shreyas Gandhi ¹, Julia Han ², Crystal Bockoven ³, Philipp Dahm ⁴

Abstract

Introduction and Objectives:

High-quality systematic reviews (SRs) have a paramount role in informing evidence-based clinical practice. We assessed the quality of published systematic reviews in the urological literature as an extension of a prior study.¹

Methods:

We systematically searched PubMed and hand-searched the table of contents of four major urological journals from 1/2013 to 12/2015 to identify SRs related to questions of prevention and therapy. Two independent reviewers assessed the methodological quality using the 11-point Assessment of Multiple Systematic Reviews (AMSTAR) instrument. We performed protocol-driven analyses for the 2013–2015 time period alone and in aggregate with earlier data for the 1998–2012 time period.

Results:

The updated literature search identified 490 studies, of which 130 ultimately met inclusion criteria. The most common SR topic for 2013–2015 was oncology (68; 52.3%), followed by voiding dysfunction (28; 21.5%) and stones/endourology (10; 7.7%). The mean AMSTAR scores ± SD for 2013–2015 (n=130), 2009–2012 (n=113), and 1998–2008 (n=57) were 4.9 ± 2.4, 5.4 ± 2.3, and 4.8 ± 2.5, respectively (p=0.160). In 2013–2015, AMSTAR scores for BJU International (n=29), The Journal of Urology (n=19), European Urology (n=62), and Urology (n=20) were 5.6 ± 3.1, 5.1 ± 2.6, 4.6 ± 2.3, and 4.3 ± 2.3, respectively (p=0.205). SRs scored highest for the description of studies’ baseline characteristics (118; 90.8%) and comprehensive literature search of two or more databases (105; 80.8%). They scored lowest on conflict of interest reporting (6; 4.6%) and the inclusion of unpublished studies to avoid publication bias (10; 7.7%).

Conclusions:

There has been an exponential increase in the number of systematic reviews published in the urological literature year by year, but a stagnation of methodological quality. Systematic review authors and editors should apply established methodological standards to enhance the validity and impact of systematic reviews.

References

1.MacDonald SL, Canfield SE, Fesperman SF, et al. Assessment of the methodological quality of systematic reviews published in the urological literature from 1998 to 2008. J Urol. 2010;184:648–53. doi: 10.1016/j.juro.2010.03.127. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S64–S65.

UP-05.06: Series of systematic reviews and meta-analyses of the risk of thrombosis and bleeding in urological non-cancer surgery (ROTBUS non-cancer)

Philippe D Violette ¹, Samantha Craigie ^2,³, Arnav Agarwal ^2,⁴, Rufus Cartwright ^5,⁶, Reed A Siemieniuk ⁷, Giacomo Novara ⁸, Richard Naspro ⁹, Per Morten Sandset ^10,¹¹, Michael K Gould ¹², Gordon H Guyatt ^2,¹³, Kari AO Tikkinen ^14,¹⁵

Abstract

Introduction and Objectives:

Pharmacological thromboprophylaxis involves trading off reduction in venous thromboembolism (VTE) against increased bleeding. Here, we provide best estimates of absolute risk of VTE and bleeding in urological non-cancer surgery.

Methods:

We searched for contemporary observational studies reporting symptomatic VTE or bleeding after urological procedures. For each procedure, we accounted for use of thromboprophylaxis and length of followup, and derived best estimates of risk from the median of included studies. Primary endpoints were four-week postoperative incidence of symptomatic VTE and bleeding requiring reoperation. We stratified on patient risk factors for VTE (body mass index (BMI) >35, age >75, personal or family history). Quality of evidence was assessed using GRADE.

Results:

We included 35 studies reporting on 7 urological procedures for benign disease. Most studies (55%) were at high-risk of bias due to lack of thromboprophylaxis reporting; quality was low or very low for each body of evidence. When prophylaxis was reported, duration varied widely between procedures and studies; e.g., median was five days (range 4–42) for laparoscopic donor kidney transplantation and one day (range 0–1) for reconstructive female pelvic surgery (including vaginal prolapse and sling surgery). Risk of VTE and bleeding were both generally low for these procedures (<2%). The highest risks were found in open recipient nephrectomy and open prolapse surgery.

Conclusions:

Our results suggest prophylaxis is warranted in some procedures (kidney transplantation in large-risk patients) and not others (reconstructive female pelvic surgery in small/medium-risk patients). For those operations where the tradeoff is less clear, the decision will depend on surgeon and patient values and preferences with regard to VTE and bleeding.

Table 1.

UP-05.06. Risk (%) of VTE and bleeding requiring reoperation at 4 weeks after urological non-cancer surgery

Procedure	Outcome	Estimate by patient risk strata (%)
Donor, nephrectomy, laparoscopic	VTE	Small risk	0.4
		Medium risk	0.7
		Large risk	1.4

	Bleeding requiring reoperation		0.1

Donor nephrectomy, open	VTE	Small risk	0.3
		Medium risk	0.7
		Large risk	1.3

	Bleeding requiring reoperation		0.1

Recipient nephrectomy, open	VTE	Small risk	1.8
		Medium risk	3.7
		Large risk	7.4

	Bleeding requiring reoperation		2.4

Percutaneous nephrolithotomy	VTE	Small risk	0.4
		Medium risk	0.7
		Large risk	1.5

	Bleeding requiring reoperation		0.5

TURP or equivalent	VTE	Small risk	0.2
		Medium risk	0.4
		Large risk	0.8
	Bleeding requiring reoperation		0.2
Prolapse surgery (open)	VTE	Small risk	0.7
		Medium risk	1/3
		Large risk	2.6

	Bleeding requiring reoperation		0.4

Reconstructive female pelvic surgery	VTE	Small risk	0.2
		Medium risk	0.3
		Large risk	0.7

	Bleeding requiring reoperation		0.3

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S65.

UP-05.07: Improving access to urologists through an electronic consultation service

Luke Witherspoon ¹, John E Mahoney ¹, Erin Keely ^2,³, Clare Liddy ^4,⁵, Amir Afkham ⁶

Abstract

Introduction and Objectives:

Access to specialist services is limited by wait times to see these physicians and geographic availability of these specialists. An e-consult service, Champlain BASE (Building Access to Specialist Advice), has been implemented in our service region, facilitating access to specialists by primary care providers (PCP). Through a secure web-based system, PCPs are able to send e-referrals, instead of requesting a formal in-office referral. We analyzed the characteristics of the referred cases and the service’s impact on improving access to urologists.

Methods:

190 e-consults completed through the Champlain BASE service from March 2013 to January 2015 were analyzed. Each consult was characterized in regards to the question asked by the referring physician, the primary symptom of the referred patient, and any diagnosis made. Based on the mandatory end of case survey, we analyzed rates of referral avoidance, physician satisfaction, and overall impact on patient care.

Results:

Of 190 e-consultations, 70% were completed in less than 10 minutes. The most common clinical questions related to interpretation of imaging reports (16%), tests to choose for investigating a condition (15%), interpretation of clinical findings (14%), and the indications for urological procedures (13%). Common diagnoses were hematuria (13%), renal mass (8%), kidney stones (7%), and recurrent urinary tract infections (6%). In 35% of cases, a referral to a urologist had been contemplated and was avoided. In 8% of cases, a PCP did not believe a consultation was initially needed, but a referral ultimately was sent after the e-consultation.

Conclusions:

Our study shows that although certain clinical presentations still require a formal in-person urological consultation, e-consultations can potentially reduce unnecessary clinic visits, while identifying patients who may benefit from early urological consultation. Through both these mechanisms, we may improve timely access to urologists.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S66.

MP-06.01: Comparative analysis of surgery vs. intralesional injection therapy for ventral Peyronie’s disease

Faysal A Yafi ¹, Georgios Hatzichristodoulou ², Christopher J Knoedler ¹, Landon W Trost ³, Suresh C Sikka ¹, Wayne JG Hellstrom ¹

Abstract

Introduction and Objectives:

Approximately 10% of Peyronie’s disease (PD) patients present with ventral curvatures and, as such, there is a paucity of data describing the optimal approach for treatment. We sought to compare the outcomes of surgery (tunical plication (TP)) and intralesional injection (ILI) therapy (interferon-α2b) in men with ventral PD.

Methods:

Retrospective data was collected from two centres: Tulane University (ILI) and Technical University of Munich (TP). Collected variables included patient demographics, pre- and post-treatment sexual function, rigorous penile measurements (curvature, length, and penile vascular findings), and post-treatment outcomes.

Results:

A total of 35 patients with ventral PD (21 ILI and 14 TP) were included in the study. There were no significant differences between the two groups prior to the interventions. There was a significantly better improvement in mean curvature with TP (46.4 degrees) as compared to ILI (9.3), p<0.0001. TP was also associated with a significantly higher rate of ≥20% improvement in curvature as compared to ILI (100% vs. 67%; p=0.027). While there was no significant difference in post-treatment change in Sexual Health Inventory for Men (SHIM) scores between the groups, 36% of the ILI patients noted an improved SHIM score as compared to none in the TP group. Erect penile length was preserved or improved in 67% of the ILI group vs. 14% of the TP group; p=0.005.

Conclusions:

TP confers a better overall improvement in penile curvature as compared to ILI in patients with ventral PD. Preserved or improved erect penile length and SHIM scores may be observed in patients undergoing ILI.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S66.

MP-06.02: Contemporary analysis of the surgical management of men with Peyronie’s disease with hourglass deformity

Faysal A Yafi ¹, Georgios Hatzichristodoulou ², Julie Wang ¹, James Anaissie ¹, Suresh C Sikka ¹, Wayne JG Hellstrom ¹

Abstract

Introduction and Objectives:

Less than 10% of Peyronie’s disease (PD) patients have an hourglass deformity. We investigated the outcomes of two surgical interventions for PD patients with hourglass deformity — partial excision and grafting (PEG) or inflatable penile prosthesis (IPP) implantation.

Methods:

Retrospective data was collected from two centres: Technical University of Munich (PEG) and Tulane University Medical Centre (IPP). Collected variables included patient demographics, pre- and post-treatment sexual function, penile vascular measurements, and treatment outcomes.

Results:

A total of 50 PD patients with hourglass deformity (26 PEG (Group 1) and 24 IPP (Group 2) were included in this study. Patients in Group 1 had higher mean preoperative Sexual Health Inventory for Men (SHIM) scores (22.2 vs. 10.3; p<0.0001), required less erectile dysfunction (ED) treatment (35% vs. 79%; p=0.005), and had more non-vascular etiology on preoperative penile duplex Doppler ultrasound (PDDU) (77% vs. 21%; p<0.0001). There were no intraoperative complications, two patients in Group 1 had postoperative glans hypoesthesia, and one patient in Group 2 required surgical revision. All patients in both groups had significant ≥20% improvements in penile curvature, with mean changes of 68.1 degrees (12.7) in Group 1 and 49.6 degrees (13.5) in Group 2; p<0.0001. Resolution of hourglass deformity was achieved in 85% of patients in Group 1 and 100% of Group 2; p=0.045. The mean postoperative change in SHIM score was −0.3 (1.3) in Group 1 and 16.7 (4.7) in Group 2; p<0.0001.

Conclusions:

Both surgical options provide excellent outcomes for well-selected patients with PD and an hourglass deformity. PEG can be offered to patients with good erectile function, while the IPP remains the preferred option for patients with poor erections.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S66.

MP-06.03: Is there an association between the degree of apical striated muscle in radical prostatectomy specimens and erectile function?

Rano Matta ¹, Renu Eapen ¹, Sean C Skeldon ¹, Johan Gani ¹, Sidney B Radomski ¹

Abstract

Introduction and Objectives:

Aggressive resection at the apex during radical prostatectomy has been thought to impact erectile function.¹ We have demonstrated that the amount of striated muscle (SM) seen at the apex of radical prostatectomy pathology specimens was significantly associated with postoperative urinary incontinence. The aim of this study was to determine if there is a similar association between postoperative erectile function and the amount of SM seen in radical prostatectomy specimens.

Methods:

We reviewed the records of 61 consecutive patients at the University Health Network seen in followup after a radical prostatectomy. The primary outcome was erectile function. The pathological specimens from the prostatectomy were reviewed by two independent pathologists and the amount of SM in the specimen was quantified according to our previously described scoring system (SM score). We looked at pathological variables, including SM score, and operative variables, including nerve-sparing. Continence status and erectile function were determined based on history at the last known visit. Bivariate and multivariate analysis was conducted.

Results:

The median age in the cohort was 62.5 years (interquartile range (IQR) 58.3–66.0). Median followup was 241.4 weeks after surgery (IQR 175.3–335.9). Overall, 25% of the cohort was able to achieve erections suitable for intercourse, with 20% requiring medical therapy. In multivariate analysis, we could not demonstrate an association between the degree of SM observed in radical prostatectomy specimens and erectile function. There were no other significant variables (age, followup, prostate weight, nerve-sparing, positive margins, and continence) associated with erectile function in the multivariate regression model.

Conclusions:

In this cohort, there was no association between the amount of apical SM in prostatectomy specimens and erectile function after radical prostatectomy.

References

1.Skeldon SC, Gani J, Evans A, et al. Striated muscle in the prostatic apex: Does the amount in radical prostatectomy specimens predict postprostatectomy urinary incontinence? Urology. 2014;83:888–92. doi: 10.1016/j.urology.2013.12.055. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S67.

MP-06.04: Single-centre outcomes with synchronous dual AUS/IPP insertion through a penoscrotal incision

Faysal A Yafi ¹, Gregory C Mitchell ¹, Taylor Peak ¹, Premsant Sangkum ², Wayne JG Hellstrom ¹

Abstract

Introduction and Objectives:

Current gold standard of care therapies for patients with significant post-prostatectomy erectile dysfunction (ED) and stress urinary incontinence (SUI) are the inflatable penile prosthesis (IPP) and the artificial urinary sphincter (AUS). We sought to report our experience with dual synchronous AUS/IPP insertion through a single penoscrotal incision.

Methods:

We retrospectively collected data on 33 patients who had synchronous dual insertion of AUS/IPP through a single penoscrotal incision between 2009 and 2014. Collected data included various patient, clinical, and surgical parameters. Post-surgical outcomes including erectile function, degree of incontinence, complications, and patient and partner satisfaction rates were also collected.

Results:

The median age of the cohort was 64 (range 51–79). Comorbidites included hypertension (67%), dyslipidemia (52%), coronary artery disease (30%), diabetes (24%), with 21% of the patients receiving post-prostatectomy radiotherapy. Distribution of AUS cuff sizes was 3.5cm (33%), 4.0 cm (64%), and 4.5cm (3%). IPPs were three-piece in 70% and two-piece in 30%. At a median followup of 19 months (range 1–92), median Sexual Health Inventory for Men (SHIM) score improved from 5 to 25 and median pads per day decreased from six to one. Median patient and partner satisfaction rates were 9/10 and 10/10, respectively. Complications included three infections, two AUS cuff leaks, two AUS erosions, and one IPP distal erosion, and occurred more commonly in patients with comorbidities and/or previous radiotherapy.

Conclusions:

Dual synchronous AUS/IPP insertion through a single penoscrotal incision is a safe procedure that can yield excellent results. Diabetes mellitus and previous history of radiotherapy convey a higher risk of device infection and AUS erosion.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S67.

MP-06.05: Testosterone (T) nasal gel restores T levels in hypogonadal men with seasonal allergies

Alan D Rogol ¹, Nathan Bryson ², Natalia Tkachenko ²

Abstract

Introduction and Objectives:

Testosterone (T) nasal gel is a new Health Canada-approved T-replacement therapy (TRT). Gel is applied intranasally in a few seconds. There is no hand contact with the gel, so possible transference is negligible. In Acerus’ Phase 3 program, the incidence of symptomatic conditions was surprisingly low in patients with a history of allergic rhinitis (AR) and/or seasonal allergies. Here, we report results in hypogonadal men with emphasis on patients with a history of AR or seasonal allergies.

Methods:

Patients (n=306) received T nasal gel for up to one year. Patients were randomized to a fixed-dose (33 mg) or titration arm (22 mg). T nasal gel was self-administered using a metered-dose dispenser. Patients in the titration arm could be up-titrated to 33 mg by their physician based on the serum total T average concentration (Cavg). The primary endpoint was the percentage of subjects with Cavg in the normal range (300–1050 ng/dL) at the end of the treatment period. Safety measures included the incidence of nasal adverse events and visual nasal examination. 59 patients (19%) had a history of AR or seasonal allergies.

Results:

In hypogonadal patients with a medical history of AR or seasonal allergies, normal T levels were achieved in 79% of subjects, with the highest dose achieving 94% within that range. Normal T levels in the intention-to-treat (ITT) population were 73% (all doses) and 90% (highest dose). Discontinuation rates were similar in ITT and allergy populations and nasal examination showed no abnormal findings at one year. Most surprising was the very low incidence of seasonal allergy symptoms (3/52 or 5.8%) reported by susceptible patients while on treatment for ≥6 months. Reduced allergic reactivity is believed to be related to the gel formulation. In prior studies, the concomitant use of a decongestant did not modify absorption of T in those with symptomatic AR.

Conclusions:

Testosterone nasal gel restored normal T levels in hypogonadal men, including those with a medical history of allergic rhinitis or seasonal allergies.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S67–S68.

MP-06.06: Single-incision vasectomy reversal (SIVR): Less pain without compromising surgical outcomes

Doug C Cheung ¹, Mary K Samplask ¹, Sammi Tobe ¹, Ethan D Grober ¹

Abstract

Introduction and Objectives:

The single-incision vasectomy reversal (SIVR) offers an innovative approach to VR by which the entire procedure is performed through a single midline mini-incision. Much like the no-scalpel vasectomy, the SIVR was designed with the goal of minimizing surgical dissection and reducing morbidity following VR. As a quality-based initiative, the current report highlights outcomes following SIVR compared to a bilateral incision VRs.

Methods:

A prospective VR database was used to identify consecutive cases of primary bilateral vasovasostomy VRs. Cases were stratified into SIVR or bilateral incision VR (BIVR). Baseline patient characteristics, measures of pain, and functional recovery and postoperative patency outcomes were compared between the two groups. A SIVR was considered in the absence of significant vasal gaps, large sperm granulomas, and/or limited mobility of the scrotal contents. As in the no-scalpel vasectomy (NSV), the SIVR begins by stabilizing the vas directly under the scrotal skin at the midline raphae. The NSV ring clamp is used to capture the vas in the midline at the vasectomy occlusion site. A single small (<1 cm) opening in the scrotal skin is created and vas is gently exposed and delivered through the midline incision. The mobile and compliant the scrotal skin allows the midline incision to be shifted and brought to the vas, as opposed to the vas being mobilized to the anatomical midline. Once both ends of the vas have been delivered and stabilized in a vas approximator, the surgical microscope is used to complete the anastamosis according to surgeon preference. The contralateral vas is approached via the same incision, but through separate opening in the dartos muscle. This fosters a tension-free anastomosis, with each vas remaining in its respective hemi-scrotal space separated by the dartos muscle in the midline. If necessary, the small opening in the skin closed with a single dissolvable suture.

Results:

Of 1060 consecutive VRs performed by a single surgeon (EG), 100 consecutive cases of each SIVRs and BIVRs (200 cases total) were identified for a comparative quality-based analysis. Following the introduction of the single-incision approach to surgical practice, a SIVR was completed in 23% of patients. Baseline patient characteristics and postoperative outcomes are summarized in Table 1. Patients who had a SIVR reported less pain during their first week of recovery, quicker resolution of pain, and returned to work earlier.

Conclusions:

A SIVR is feasible option in well-selected men undergoing vasovasostomy without compromising patency rates or semen parameters. Minimizing the number and size of the incisions and the degree of surgical dissection involving the spermatic cord and testis appears to translate into less postoperative discomfort and quicker functional recovery.

Table 1.

MP-06.06.

Surgical approach	Male age	Female age	Vasal occlusion interval	% patency (mobile sperm)	Sperm concentration (million/ml)	% motile sperm	% normal morphology	Total motile sperm count (×10⁶)
SIVR	38	33	5.5	94%	31	49	46	46
BIVR	41	38	7.8	93%	31	57	64	62

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S68.

MP-06.07: Transseptal crossover vasoepididymostomy and crossover vasovasostomy: Rare but useful techniques to restore fertility

Stephen Mannas ¹, James Furr ¹, Puneet Sindhwani ¹

Abstract

Introduction and Objectives:

Vasoepididymostomy is a procedure used to restore patency in the context of an epididymal obstruction. In rare conditions, the spermatogenesis on one side may not be associated with patency of the vas deferens ipsilaterally. In such cases, transseptal crossover vasoepididymostomy (TSCOVE) or transseptal crossover vaso-vasostomy (TSCOVV) is an option to restore patency. We describe our technique and outcome in treating a patient with congenital unilateral absence of vas deferens (CUAVD) and contralateral testicular atrophy, as well as review the literature looking at techniques and outcomes of TSCOVE and TSCOVV.

Methods:

A 30-year-old azoospermic male with left CUAVD complicated by high-riding testicle, agenesis of corpus and cauda epididymis, and atrophy of the contralateral testicle underwent a successful TSCOVE via testicular transposition with high cord mobilization. Successful return of ejaculated sperms was achieved. To our knowledge, this is the first description of such technique in a patient with CUAVD. The review of literature discussing TSCOVE or TSCOVV yielded four articles published between 1985 and 2003 that together described 17 and 26 cases of each procedure respectively whose outcomes were reviewed.¹^–⁴

Results:

A review of literature along with our case showed a total patency rate of 82.35% in 17 TSCOVE cases and a pregnancy rate of 50% in 14 couples. This is in comparison with patency and pregnancy rates of 60% and 30%, respectively for 20 TSCOVV cases and 79.2% and 35.8% for all ipsilateral vasoepididymostomies in general.⁵ Differences in repair technique, as well as causes of obstructive azoospermia — the most common being surgical injury — did exist between studies.

Conclusions:

In the era of sperm retrieval and assisted reproduction, the literature supports that TSCOVE and TSCOVV using high cord release remain useful techniques to restore patency and fertility in patients with complex obstructive azoospermia.

Table 1.

MP-06.07.

Study	TSCOVE			TSCOVV
Study	Cases	Number of patencies/followup patients	Pregnancies/couples	Cases	Number of patencies/followup patients	Pregnancies/couples	Cause of vasal obstruction
Lizza et al.	-	-		11	4/8 (50%)	2/8 (25%)	Multiple
Pasqualotto et al.	3	3/3 (100%)	3/3 (100%)	2	1/2 (50%)	0/2 (0%)	Iatrogenic injury
Sabanegh et al.	10	8/9 (88.89%)	2/7 (28.57%)	-	-	-	Unknown
Sheynkin et al.	4	2/4 (50%)	2/4 (50%)	12	7/10 (70%)	4/10 (40%)	Iatrogenic injury
Mannas et al.	1	1/1 (100%)	-	-	-	-	Agenesis
Total	18	14/17 (82.35%)	7/14 (50%)	25	12/20 (60%)	6/20 (30%)	-

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References

1.Lizza EF, Marmar JL, Schmidt SS, et al. Transseptal crossed vasovasostomy. J Urol. 1985;134:1131–2. doi: 10.1016/s0022-5347(17)47657-9. [DOI] [PubMed] [Google Scholar]
2.Pasqualotto FF, Pasqualotto EB, Agarwal A, et al. Results of microsurgical anastomosis in men with seminal tract obstruction due to inguinal herniorrhaphy. Rev Hosp Clin Fac Med Sao Paulo. 2003;58:305–9. doi: 10.1590/S0041-87812003000600003. [DOI] [PubMed] [Google Scholar]
3.Sabanegh E, Jr, Thomas AJ., Jr Effectiveness of crossover transseptal vasoepididymostomy in treating complex obstructive azoospermia. Fertil Steril. 1995;63:392–5. doi: 10.1016/s0015-0282(16)57374-9. [DOI] [PubMed] [Google Scholar]
4.Sheynkin YR, Hendin BN, Schlegel PN, et al. Microsurgical repair of iatrogenic injury to the vas deferens. J Urol. 1998;159:139–41. doi: 10.1016/S0022-5347(01)64036-9. [DOI] [PubMed] [Google Scholar]
5.Peng J, Yuan Y, Zhang Z, et al. Microsurgical vasoepididymostomy is an effective treatment for azoospermic patients with epididymal obstruction and prior failure to achieve pregnancy by sperm retrieval with intracytoplasmic sperm injection. Hum Reprod. 2014;29:1–7. doi: 10.1093/humrep/det385. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S68.

MP-06.08: Outcome analysis of patients with Peyronie’s disease who elect non-invasive management

Landan Macdonald ¹, Luke Armstrong ¹, Kyle Lehmann ², Matthew R Acker ¹, Gavin M Langille ¹

Abstract

Introduction and Objectives:

Peyronie’s disease (PD) affects approximately 1% of men and has numerous proposed treatments. Invasive management options include surgical or injectable therapy, while penile traction therapy with vacuum erection device (VED) represents a noninvasive approach. The objective of the present study is to assess outcomes for patients with PD who opt for non-invasive management.

Methods:

Retrospective analysis of clinical data was performed for patients assessed for PD between July 2014 and November 2015 who were followed for at least three months and opted for non-invasive therapy. All patients were instructed to initiate traction therapy with VED for 10 minutes twice per day. Patients were assessed for degree of Peyronie’s deformity and erectile function at initial and subsequent encounters.

Results:

In all, 24 patients met the inclusion criteria. The mean (standard deviation (SD)) age was 57 (9.8) years, and the mean (SD) duration of PD prior to assessment was 23 (16.8) months. The mean (SD) duration of followup was nine (4.7) months. At followup, 16 men had not purchased a VED; 15 cited financial concerns, one was unable to contact the supplier. Among patients who did not use a VED, five showed improvement, 10 remained stable, and one had worsening curvature, with no significant change for this group in mean initial (SD) and followup (SD) curve of 52 (20)° and 48 (20)°. All eight men who initiated VED traction therapy had an improvement in curvature, with a significant mean improvement in initial (SD) and followup (SD) curve of 63 (23)° and 32 (19)° respectively (p<0.001). No complications were noted.

Conclusions:

In patients who opt for non-invasive management of PD, VED traction therapy provides improved curvature resolution compared to those who do not use such a device.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S69.

MP-06.09: Intracavernosal injection of Botulinum toxin to improve erectile function in older rats

Jeffrey Campbell ^1,², Ling De Young ², Sidney B Radomski ³, Raidh Alzubaidi ^1,², Gerald B Brock ^1,²

Abstract

Introduction and Objectives:

Erectile dysfunction (ED) in the aging male is exceptionally common and difficult to treat. ED in this population is multifactorial, with links demonstrated to structural changes in the penis, alterations in contractile properties through nNOS and RhoA pathways and the systemic effects of comorbid conditions. Botulinum toxin (BTX) has many therapeutic uses in medicine due to its effect on skeletal and smooth muscle relaxation. In this novel study, we investigated BTX utility as a treatment for ED in the aging population.

Methods:

10 male Sprague Dawley rats aged 8.5 months were used and randomized into BTX or control groups. Under microscopic visualization a 30-gauge needle was used to inject the rats’ corpora with either 10 units of BTX in normal saline (NS) or 80 µmL of NS. Rats were observed for seven days for any complications. On Day 8, erectile function was assessed via cavernous nerve electrostimulation-induced intracavernosal pressure change (ICP). Penile tissues were harvested and analyzed with Masson’s trichrome stain and immunohistologic staining for smooth muscle a-actin.

Results:

There were no significant complications from the injections in either group. The BTX group had a significantly higher ICP on Day 8 following injection when compared to the control group (79.1 ± 5.4 cmH₂0 vs 54.3 ± 4.5 cmH₂0; p<0.05). The BTX group had a larger sinusoidal volume and thinner cavernosal smooth muscle.

Conclusions:

Intracavernosal injection of BTX appears to be safe in rats. BTX injection increases sinusoidal volume by enhancing cavernous smooth muscle relaxation and subsequently allows an increase in blood flow and ICP. This is a novel study investigating BTX as a potential treatment for ED in the aging male. Short-term data is promising, but studies with longer followup are required to determine duration of efficacy. This animal model can be used as a trigger to investigate BTX as an off-labelled use for ED, particularly as salvage therapy among PDE5i non-responders or partial responders.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S70.

MP-07.01: Rapid prediction of personalized response to chemotherapy using sub-millimeter ex-vivo biopsy samples on chip

Muhammad Abdul Lateef ¹, Benjamin Péant ¹, Nassim Rousset ², Kayla Simeone ¹, Jennifer Kendall-Dupont ¹, Adriana Mari Orimoto ¹, Anne-Marie Mes-Masson ¹, Thomas Gervais ², Fred Saad ¹

Abstract

Introduction and Objectives:

Evaluating prostate cancer response to therapy can often take three months and decisions should not be made before that time according to Prostate Cancer Clinical Trials Working Group (PCWG)-2 recommendations. Early response predictor identification is a major objective towards personalized medicine. The emergence of microfluidic devices has allowed for ex-vivo response measurement to a given therapy in 3D tumour tissue. We have optimized a method to obtain microdissected tissues (MDTs) from patient biopsies, with a viability that is maintained for 14 days. Using a microfluidic, on-chip system, we studied the ex-vivo response of the MDTs to a given chemotherapeutic drug by flow cytometry.

Methods:

We have developed a method to precisely section biopsies into MDTs of sub-millimeter size. We have also designed a microfluidic chip, capable of trapping 25 MDTs, in which they can be exposed to different drugs. With our novel approach, we have initiated drug testing on patient samples using different combinations of docetaxel alone (100 nM) or in combination with bicalutamide (1 mM). The treatment regimen was initiated after 24–48 hours of tissue recovery, post-surgery. The following cycles of treatment was performed on chip: first treatment for 24 hours, first recovery for 48 hours, second treatment for 24 hpurs, second recovery for 48 hours, then cell viability analysis.

Results:

After 24 hours in culture, we observed more than 85% viability of MDTs. We observed a variable response in individual patient samples treated with per protocol on chip (<65–100% survival). For each patient included in our study, we predicted a personalized potential drug response profile based on the ex-vivo response to tested drugs. We are presently comparing these profiles to the clinical response to ongoing therapy in these patients.

Conclusions:

The ex-vivo drug response of MDTs from patient biopsy samples on-chip can be performed in a time-effective manner and may eventually contribute to a more personalized approach to clinical decision-making.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S70–S71.

MP-07.02: Prostate stereometry by transrectal ultrasonography and magnetic resonance imaging is significantly correlated to the actual volume measured after radical prostatectomy

Mohammed Nouh Ahmed ^1,², Antonio Finelli ¹, Girish S Kulkarni ¹, Robert J Hamilton ¹, Ants Toi ³, Neil E Fleshner ¹

Abstract

Introduction and Objectives:

To compare prostate volumes obtained by transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI) to assess the reliability of both techniques in predicting the actual volume.

Methods:

Data of 825 prostate cancer (PCa) patients who underwent radical prostatectomy between October 2010 and May 2014 was reviewed. A total of 134 had both preoperative TRUS and MRI for prostate evaluation and fulfilled the inclusion criteria. Prostate volume (PV) measured by TRUS and MRI were compared to the actual volume reported after surgery. Prostate size was estimated using the prolate ellipsoid formula (height × width × length xϖ/6); with the antero-posterior (A–P) diameter measured using a mid-sagittal view for TRUS and an axial view for MRI. Also, the relation of PV estimates to clinic-pathological parameters of PCa was assessed. Pearson’s correlation, linear regression, and paired t-test were performed to compare PV estimated via both imaging modalities.

Results:

The mean PV was 39.9 ± 18.3, 42.5 ± 21.3, and 49.7 ± 21.3 for TRUS, MRI, and the actual volume, respectively. The average TRUS- and MRI-based PV was significantly correlated to and underestimated the actual volume (R=0.898; p<0.001 and R=0.899; p<0.001, respectively) and to each other (R=0.903; p<0.001). Stratifying our cohort into three groups using 30 and 60 ml actual volume as cutoff points, both techniques remained correlating to the actual volume and to each other and were underestimating the PV, which was only significant in the large prostate group. Also, neither preoperative estimates, nor the actual volume was correlated to any of clinic-pathological parameters in our patients.

Conclusions:

PV estimations by TRUS and MRI are highly correlated to the actual volume. So, in the hands of an experienced sonographer, TRUS is not only efficient and economic, but also an accurate and reproducible modality to estimate prostate size.

Table 1.

MP-07.02. Correlation of PV to other clinic-pathological parameters in PCa patients

		TRUS	MRI	Actual	PSA	Gleason	Stage	RISK	Surgery
TRUS	Pearson correlation	N/A	0.903^**	0.898^**	0.097	0.102	0.090	0.035	−0.206^*
TRUS	Sig. (2-tailed)	N/A	0.000	0.000	0.267	0.240	0.301	0.684	0.017
MRI	Pearson correlation	0.903^**	N/A	0.899^**	0.091	0.092	0.063	0.025	−0.158^*
MRI	Sig. (2-tailed)	0.000	N/A	0.000	0.295	0.288	0.471	0.777	0.068
Actual	Pearson correlation	0.898^**	0.899^**	N/A	0.063	0.100	0.141	0.078	−0.179^*
Actual	Sig. (2-tailed)	0.000	0.000	N/A	0.471	0.253	0.104	0.371	0.038
PSA	Pearson correlation	0.097	0.091	0.063	N/A	0.355^**	0.399^**	0.439^**	0.310^**
PSA	Sig. (2-tailed)	0.267	0.295	0.471	N/A	0.000	0.000	0.000	0.000
Gleason	Pearson correlation	0.102	0.092	0.100	0.355^**	N/A	0.401^**	0.454^**	−0.334^**
Gleason	Sig. (2-tailed)	0.240	0.288	0.253	0.000	N/A	0.000	0.000	0.000
Stage	Pearson correlation	0.090	0.063	0.141	0.399^**	0.401^**	N/A	0.861^**	−0.230^**
Stage	Sig. (2-tailed)	0.301	0.471	0.104	0.000	0.000	N/A	0.000	0.007
RISK	Pearson correlation	0.035	0.025	0.078	0.439^**	0.454^**	0.861^**	N/A	−0.286^**
RISK	Sig. (2-tailed)	0.684	0.777	0.371	0.000	0.000	0.000	N/A	0.000
Surgery	Pearson correlation	−0.206^*	−0.158^*	−0.179^*	−0.310^**	−0.334^**	−0.230^**	−0.286^**	N/A
Surgery	Sig. (2-tailed)	0.017	0.068	0.038	0.000	0.000	0.007	0.001	N/A

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^*

Correlation is significant at the 0.1 level (2-tailed)

^**

Correlation is significant at the 0.01 level (2-tailed)

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S71.

MP-07.03: An update on hospital admission rates for urological complications after transrectal ultrasound-guided prostate biopsy

Garbens Alaina ¹, Christopher JD Wallis ¹, Refik Saskin ², Ying Liu ², Robert K Nam ¹

Abstract

Introduction and Objectives:

We were the first to report in 2010 rising rates of complications following transrectal ultrasound (TRUS)-guided prostate biopsy for prostate cancer detection from 1996–2005. Many centres have since confirmed these findings. We conducted a followup study from 2006 to 2013 to further examine these rates.

Methods:

This was a retrospective, population-based study of men who underwent TRUS-guided prostate biopsy in Ontario, Canada between January 1, 2006 and December 31, 2013. Using the Canadian Institute of Health Information (CIHI) Registry, provincial fee codes, and the Ontario Cancer Care Registry, we were able to determine mortality rates and hospital admission rates within 30 days post-TRUS prostate biopsy for hematuria, urinary obstruction, and genitourinary infection.

Results:

In total, 61 910 men underwent a TRUS-guided prostate biopsy from 2006–2013. The overall mortality rate was 0.08% and did not change throughout the study. We focused only on the healthy men (30 996/61 910) with no cancer from biopsy. The 30-day hospital admission rate was 3.45% for men without prostate cancer. Among them, 76.5% (1128/1460) men were admitted due to infection. The rates of 30-day hospital admission due to infection did not significantly increase from 2006–2013 (p=0.74). The adjusted odds ratio for admission for infection was 1.21 (95% CI 0.38–3.89) for patients from 2013, compared to patients in 2006. The number of TRUS biopsies performed annually remained stable and then abruptly fell by 30.6% in 2013 compared to the average annual biopsy rate. The rate of hospital admission in 2013, however, remained the same at 4.1% (compared to 4.0% in 2006).

Conclusions:

The 30-day post-TRUS biopsy hospital admission rates remained stable for the duration of the study. Interestingly, we witnessed an abrupt drop in biopsy rates in 2013, which could be due to the recent U.S. Preventative Services Task Force (USPSTF) recommendation against PSA screening.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S71–S72.

MP-07.04: Initial Canadian experience with 18 F fluoromethylcholine positron emission tomography/computed tomography in biochemical recurrence after definitive treatment of prostate cancer

Franck Bladou ¹, Simon Gauvin ², Stephan Probst ³, Yannick Cerentola ¹, Maurice Anidjar ¹

Abstract

Introduction and Objectives:

To correlate 18 F fluoromethylcholine positron emission tomography/computed tomography (18F-FCH PET/CT) results with patient characteristics and other conventional imaging modalities and to determine factors predictive of positivity.

Methods:

Retrospective study including 44 18F-FCH PET/CT scans of patients with (biochemical recurrence (BCR) after initial radical prostatectomy (RP) or radiation therapy (RT). Results were compared to findings on magnetic resonance imaging (MRI), CT, bone scan (BS), and histological analysis when available. Univariate and multivariate analysis were performed to correlate results with qualitative and quantitative patient characteristics (age, trigger prostate-specific antigen (PSA), doubling time (PSADT), T/N stage, Gleason score, initial/salvage treatment, concomitant androgen-deprivation therapy).

Results:

26 PET scans (59%) were positive, 14 negative (32%), three equivocal (7%), and one non-diagnostic (2%). Of the positive PET scans, 11 demonstrated local recurrence (10 in patients with initial treatment consisting of RT and one for RP), 11 regional/distant lymph nodes (10 RP, one RT), two bone metastasis and two LN + bone metastasis. Among the 26 positive PET scans, 15 underwent conventional imaging (CT, BS, and/or pelvic MRI), of which it was negative in three patients. The age (p=0.003), trigger PSA (p=0.03), PSA velocity (p=0.04), and PSADT (p=0.046) were significantly different when comparing positive and negative PET scans. Using univariate log regression analysis, patients with positive PET scans were significantly more likely to have had RT initially (OR 6.0, 95% CI 1.1–32.3) and a trigger PSA level higher than 2 ng/mL (OR 15.3, 95% CI 2.6–91.9). Trigger PSA of 2.6 ng/mL and PSADT of 4.3 months had the optimal capacity to differentiate between positive and negative scans (sensitivity 86% and 79%, specificity 71% and 50%, respectively; ROC curves).

Conclusions:

18 F-FCH PET/CT demonstrates high detection rate for local, lymph node and bone metastases in BCR patients. A trigger PSA above 2.6 ng/mL seems optimal for appropriate patient selection.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S72.

MP-07.05: Anatomic location of positive margins vary between surgeons during robotic radical prostatectomy

Ravin J Bastiampillai ¹, Luke T Lavallee ^1,², Sonya Cnossen ², Ranjeeta Mallick ², Ilias Cagiannos ¹, Christopher G Morash ¹, Rodney H Breau ^1,²

Abstract

Introduction and Objectives:

Surgical technique is associated with risk of positive tumour margins during radical prostatectomy. The purpose of this study was to determine if the risk of a positive surgical margin at specific anatomic locations varied by surgeon.

Methods:

All patients who received a robotic radical prostatectomy at The Ottawa Hospital between October 2011 and September 2015 were reviewed. Patient characteristics, clinical data, and pathological findings were obtained from the medical record. Prostatectomy specimens were reviewed by genitourinary pathologists. The presence of a positive surgical margin was reviewed at four anatomic locations of the prostate: anterior apex, posterior apex, non-apex posterolateral, and bladder neck.

Results:

During the study period, 571 patients received a radical prostatectomy by one of six surgeons. The number of procedures per surgeon ranged from 24–185. Median preoperative prostate-specific antigen (PSA) was 6.9 (interquartile range (IQR) 5.0, 9.5) and 250 (43.9%) patients had palpable tumours. Gleason sum was 3 + 3 in 37 (6%), 3 + 4 in 325 (57%), 4 + 3 in 163 (29%), 4 + 4 in 8 (2%), and 4 + 5 in 35 (6%). Almost half of patients had pT3 tumours (259; 45%). There were no statistically significant differences in baseline characteristics between surgeons (p>0.05). Bilateral nerve-spare was performed in 325 (57%), unilateral nerve-spare in 135 (24%) and no nerve-spare in 111 (19%). There were statistically significant differences in positive surgical margins between surgeons at the posterior apex (range 5–27%; p<0.0001) and the bladder neck (range 0–7.4%; p=0.03). There was no difference between surgeons for the risk of a positive surgical margin at the anterior apex (36; 6.3%; p=0.9) or the non-apex posterolateral (85; 15%; p=0.9) locations.

Conclusions:

Significant variability in the incidence of positive surgical margins between surgeons was observed at the posterior apex and bladder neck. These data suggest that an adjustment in surgical technique may improve oncologic outcomes.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S72.

MP-07.06: Baseline prostate-specific antigen levels in midlife predict total and aggressive prostate cancer in African-American men

Mark A Preston ¹, Kathryn M Wilson ², Travis Gerke ², Sigrid Carlsson ³, Daniel D Sjoberg ⁴, Adam S Kibel ¹, Quoc-Dien Trinh ¹, Lisa Signorello ⁵, Mark Steinwandel ⁶, Andrew Vickers ⁴, Hans Lilja ³, Lorelei Mucci ²

Abstract

Introduction and Objectives:

Prostate-specific antigen (PSA) level in midlife predicts prostate cancer (PCa) mortality in Caucasian populations. It is poorly studied whether PSA measured during midlife predicts aggressive PCa among African-American (AA) men.

Methods:

We performed a nested case-control study among AA men age 40–65 years who gave blood at enrollment in the Southern Community Cohort Study between 2002 and 2009 and followed for median of nine years. Baseline kallikrein levels (total PSA, free PSA, intact PSA, and human kallikrein 2[hK2]) were measured in 197 PCa cases and 569 age-matched controls. 55 men had aggressive PCa defined as Gleason 4 + 3 = 7, AJCC Stage III or IV, or cancer-specific death. Exact conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for association between PSA and risk of total/aggressive PCa. Area under the curve (AUC) for prediction of total/aggressive PCa by PSA and a previously reported four-kallikrein risk score was calculated using logistic regression.

Results:

Median PSA among controls was 0.72, 0.80, 0.94, and 1.03 ng/mL for men 40–49, 50–54, 55–59, and 60–64 years, respectively. Risk of total PCa was strongly associated with baseline PSA in midlife. PSA was also highly predictive of aggressive PCa. All 22 aggressive cases in men <55 years occurred among those with PSA above the age-specific median; among men 40–49 years, all nine cases of aggressive PCa were among those with PSA >90th percentile. Across age groups, the OR of aggressive PCa for PSA >90th percentile vs. < median was 38.8 (95% CI 10.0–237), using age-specific cut-points. PSA in midlife predicted total (AUC 0.88, 95% CI 0.85–0.91) and aggressive (AUC 0.87, 95% CI 0.81–0.92) PCa with high discrimination. Among men with total PSA >2 ng/ml, the four-kallikrein risk score improved prediction of aggressive PCa compared to PSA alone.

Conclusions:

PSA level in midlife strongly predicted total and aggressive PCa in a cohort of AA men subject to opportunistic screening.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S72–S73.

MP-07.07: Inhibiting invadopodia formation can abrogate cancer cell extravasation and prevent prostate cancer metastasis

Khurram Siddiqui ¹, Metthew Arora ¹, Yohan Kim ¹, Patrick Telmer ¹, David Desantis ¹, Emily Jardine ¹, LK Joseph Chin ¹, Jonathan I Izawa ¹, Hon Leong ¹

Abstract

Introduction and Objectives:

Inhibition of Tks4 and Tks5 expression can block invadopodia formation in metastatic cancer cells, leading to the inability of these cells to undergo extravasation. We sought to determine if this was also the case in metastatic prostate cancer cells.

Methods:

We used PC3MLN4 and LNCAP prostate cancer cell lines. Lentiviral infection was performed to knockdown four clones each for Tks4 and Tks 5 for both the cell lines. Gene knock-down efficiency was assessed by quantitatve reverse transcription polymerase chain reaction (qRT-PCR). Using CAM-model, we then assessed the extravasation efficiency of these cells (labeled with green fluorescent protein) using confocal microscopy.

Results:

Using PC-3M-LN4 and LNCaP metastatic prostate cancer cells, we knocked down Tks4 and Tks5 mRNA levels with RNAi to 64% and 78% of control levels respectively. In our model of in vivo cancer cell extravasation, we determined that extravasation rates dropped to 12+/−3% and 3.4+/−1.6% compared to 37.3+/−5.8% in empty vector controls with the PC-3M-LN4 cell line. When the same cells were used to understand the impact on metastatic colony formation, 12.3+/−4.6 and 0.4+/−1.2 colonies were observed (n>8/group) for shTks4 and shTks5 PC-3M-LN4 cells compared to 47+/−9 in shLUC control cells. However, when in vitro gelatin-Alexa594 ECM degradation assays were performed, no degradation signal voids were observed in any of the cell lines including the controls. Instead, we performed intravital imaging experiments to determine the incidence of cell protrusions at t=5 hours post-injection, revealing few to no cells forming protrusions in vivo, whereas the control cells formed protrusions in 10% of cells at that time point.

Conclusions:

Blocking the expression of Tks4/5 in prostate cancer cells abrogated cancer cell extravasation leading to no metastatic colonies formed in vivo. These findings suggest that targeting key steps of the metastatic cascade may be a realistic approach for advanced prostate cancer treatment.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S73.

MP-07.08: Treatment trends and cost for localized prostate cancer in elderly patients

Anne Sophie Valiquette ¹, Paolo Dell’Oglio ², Zhe Tian ¹, Sami Leyh-Bannurah ³, Vincent Trudeau ¹, Fred Saad ¹, Alberto Briganti ², Francesco Montorsi ², Alessandro Larcher ², Pierre Karakiewicz ¹

Abstract

Introduction and Objectives:

The absolute and proportional numbers of elderly patients diagnosed with localized prostate cancer (PCa) are on the rise. We examined treatment trends and reimbursement figures in localized PCa patients aged 80 years and more.

Methods:

Between 2000 and 2008, we identified 30 217 localized PCa patients aged 80 years and more in Surveillance Epidemiology and End Results (SEER)-Medicare-linked database. Alternative treatment modalities consisted of conservative management (CM), radiation therapy (RT), radical prostatectomy (RP), and primary androgen-deprivation therapy (PADT). For all four modalities, use and cost trends were examined.

Results:

PADT was the most frequently used treatment modality between 2000 and 2005 in elderly patients. CM became the dominant treatment modality from 2005 to 2008. RP rates were marginal and RT ranked third. RT annual utilization rate increased from 20.77% in 2000 to 29.13% in 2008. The highest median individual cost was related to RT, ranging from $29 343 in 2000 to $31 090 in 2008, followed by RP (from $20 560 in 2000 to $19 580 in 2008), PADT (from $18 901 in 2000 to $8000 in 2008), and CM (from $1 824 in 2000 to $1938 in 2008). RT contributed to most of cumulative cost from 2003 (49.24%) to 2008 (72.97%). PADT share of cost ranked first from 2000 (54.56%) to 2002 (50.49%), but decreased by 19.40% in 2008. CMs contribution to cumulative cost increased from 4.42% in 2000 to 6.96% in 2008. RP share of cost was stable during the study period.

Conclusions:

Our results, focusing on localized PCa treatment in patients aged 80 years and more, showed an important increase in rates, median cost, and proportion of cumulative cost related to RT. Moreover, a surprising elevated proportion of elderly patients received RT.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S73.

MP-07.09: Focal high-intensity focused ultrasound for localized prostate cancer: A single-centre experience

Nicholas Haddad ¹, Maurice Anidjar ¹, Oleg Loutochin ¹, Franck Bladou ¹

Abstract

Introduction and Objectives:

Men with localized prostate cancer (PCa) are currently faced with the decision to either undergo radical therapy or enter active surveillance protocol. Focal high-intensity focused ultrasound (HIFU) may be an alternative treatment option for some of these men that may be spared the side effects of radical prostatectomy and radiation or released from anxiety of living with untreated cancer in active surveillance protocol. The objective of this study is to present preliminary outcomes in selected patients treated with focal HIFU.

Methods:

We report preliminary findings of a prospective, single-centre, phase 2, single-arm, cohort study offering focal HIFU (Ablaterm^®/Focal One^®) to men with histologically proven localized, low-to-intermediate-risk PCa (prostate-specific antigen (PSA) <15, Gleason score (GS) ≤7) with a magnetic resonance imaging (MRI) index lesion confirmed by MR-targeted transrectal ultrasound (TRUS) biopsies. Factors assessed included PSA levels, control MR-targeted TRUS biopsy at six months post-HIFU, oncologic results, re-treatments, side effects, and validated questionnaires assessing urinary and bowel function, sexuality, and quality of life.

Results:

A total of 21 patients have been recruited from September 2013 to January 2016, 14 of whom had control MRI-guided biopsy at six months. The mean followup is 9.9 months. In the group of patients with six-month control biopsy, the mean initial PSA was 6.9 ng/ml (standard deviation (SD) 2.8) and mean six-month PSA 3.2 ng/ml (SD 3.2). The mean prostate volume was 35.6 cc (SD 17.3) and the mean percent of volume treated was 41.8% (SD 6.6) of the prostate gland. Nine had negative biopsies (12 cores + targeted biopsies on the treated area) (64.2%). In five patients with positive biopsies, three had cancer in the treated area (considered as failures; 21.4%) and two in a non-treated part of the gland. Four patients have been re-treated, one underwent a radical prostatectomy, one was referred for external beam radiation and hormone therapy, and two underwent repeat focal HIFU with no complication. There have been no serious adverse events Side effects included erectile dysfunction needing phosphodiesterase type-5 inhibitor (IPDE5) in two patients (9.5%), lower urimart tract symptoms (LUTS) in three patients (14.2%), two mild hematuria, one mild rectal bleeding, and one epididymitis.

Conclusions:

Focal therapy may be a strategy that could complement the current choices available to men with localized PCa. Our preliminary experience tells us it is a safe procedure, very well-accepted by patients. However, longer followup and larger numbers of patients are needed to confirm our early results. The impact it may have on function and quality of life, in addition to its cost-effectiveness, are currently being assessed.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S73–S74.

MP-07.10: ATLAS: A randomized, double-blind, phase 3 study of ARN-509 in patients with high-risk localized or locally advanced prostate cancer receiving primary radiation therapy

Michael McKenzie ¹, David Dearnaley ², Bertrand Tombal ³, Edwina Baskin-Bey ⁴, Stephen J Freedland ⁵, Mack Roach ⁶, Anders Widmark ⁷, Alberto Bossi ⁸, Adam P Dicker ⁹, Thomas Wiegel ¹⁰, Neal D Shore ¹¹, Matthew R Smith ¹², Margaret Yu ⁴, Thian Kheoh ¹³, Shibu Thomas ¹⁴, Howard Sandler ¹⁵

Abstract

Introduction and Objectives:

At present, high-risk localized and locally advanced prostate cancer (PCa) patients receiving primary radiation therapy (RT) and long-term androgen-deprivation therapy (ADT; gonadotropin-releasing hormone [GnRH] agonist +/− antiandrogen) have a high risk of metastases and PCa-specifc death. We hypothesize that the addition of ARN-509 (JNJ 56021927), a selective androgen receptor (AR) antagonist, to GnRH agonist will improve metastasis-free survival in high-risk patients treated with primary RT.

Methods:

This is a randomized, multicentre, double-blind, placebo-controlled, phase 3 trial evaluating the efficacy and safety of ARN-509 in patients with high-risk localized or locally advanced PCa (Gleason score of ≥8 and ≥cT2c or a Gleason score of ≥7 and prostate-specific antigen ≥20 ng/mL and ≥cT2c) receiving primary RT. Stratification: Gleason score (7 or ≥ 8), N0 or N1, brachytherapy boost (yes or no), and region (North American, European Union, or other). All patients will receive active treatment with a GnRH agonist throughout the 30 28-day treatment cycles. Randomization: 1:1 to ARN-509 or control. Neoadjuvant/concurrent (cycles 1–4) to RT (74–80 Gy): ARN-509 240 mg/d vs. bicalutamide 50 mg/d; adjuvant to RT (cycles 5–30): ARN-509 240 mg/d vs. placebo. Primary endpoint: metastasis-free survival. Secondary endpoints: time to local-regional recurrence, time to castration-resistant disease, time to distant metastasis, and overall survival. Imaging with computed tomography (CT) or magnetic resonance imaging (MRI) and bone scan will be conducted at baseline and then every six months following biochemical failure until documented distant metastasis by blinded-to-arm independent central review or death. Approximately 1500 patients will be accrued globally to provide appropriate statistical power to detect the hypothesized risk reduction (25%) in metastasis or death. An independent data monitoring committee is commissioned to review trial data.

Footnotes

ClinicalTrials.gov Identifier: NCT02531516.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S74.

MP-07.11: WITHDRAWN

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S74.

MP-07.12: MRI-fused cone beam CT-guided biopsy of the prostate: A novel method of prostate biopsy

Jason P Izard ^1,², D Robert Siemens ^1,², Michael J Leveridge ^1,², Alexandre Menard ³

Abstract

Introduction and Objectives:

Real-time 3D fluoroscopy guidance using a cone beam computed tomography (CT) fused to a magnetic resonance imaging (MRI) can project an MRI-detected lesion on to the screen of a cone beam CT scan (Fig. 1). This allows an operator to advance a needle directly into the software-generated lesion using real-time fluoroscopy to confirm biopsy needle placement within the lesion (Fig. 2). To date, there have been no reports or investigations on the use of this new technology for prostate biopsies. We prospectively assessed the safety and feasibility of MRI-fused cone beam CT-guided prostate biopsies.

Methods:

We prospectively identified six patients who had either negative transrectal ultrasound of the prostate (TRUSP) biopsies or TRUSP biopsies showing small volume Gleason 6 disease with a clinical suspicion of higher-volume, higher-grade disease. All patients had an MRI showing a prostate imaging reporting and data system (Pi-RADS) 4 or 5 lesion in the prostate. Patients underwent site-directed MRI-fused cone beam CT-guided biopsies through a transgluteal approach. Biopsy results and immediate and 30-day complication rates were recorded.

Results:

The biopsies were well-tolerated by all patients. No patient experienced an immediate or 30-day complication. Of the six patients, three had previous negative biopsies and three had biopsies harbouring low-volume Gleason 6 disease. Of the three patients with previous negative biopsies, one patient had a positive CT-guided biopsy with seven of nine cores positive for Gleason 4 + 4 = 8/10. Of the three patients with low-volume Gleason 6 disease, two patients had CT-guided biopsies showing prostate cancer; one patient with similar low-volume Gleason 6 disease and the second patient’s CT-guided biopsy showed upgrading with five out of five cores positive for Gleason 3 + 4 = 7/10 prostate cancer.

Conclusions:

MRI-fused cone beam CT-guided biopsy of the prostate appears to be technically feasible with a reasonable safety profile. Additional experience will be required to further delineate the diagnostic accuracy of this novel method of prostate biopsy.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S74–S75.

MP-07.13: The impact of public awareness campaigns on internet searches for prostate cancer and PSA testing: Comparison to breast and colon cancer

Richard Veldhoen ¹, Rano Matta ², Michael J Leveridge ³

Abstract

Introducation and Objectives:

Cancer Awareness Months (CAMs) aim to raise awareness and funds for cancer charities and research. The American Cancer Society recognized 12 distinct CAMs. Over 2/3 of people seek health information on the internet. We used internet search volumes to identify changes in relative volume of cancer- and screening-specific searches during CAMs.

Methods:

We used Google Trends to identify relative search volumes for prostate, breast, and colon cancer, as well as “PSA test,” “mammogram,” and “colonoscopy” from 2004–2014. We searched volumes in Canada, the United States (U.S.), Britain (U.K.), and Australia. Google Trends reports search terms as a proportion of all Google searches in the same time period; relative results over time are normalized to values between 0 and 100. We used ANOVA to compare mean search volumes for each month against all other months; the Tukey-Kramer post-hoc test assessed CAMs agains each other month.

Results:

Breast cancer search volume was always much higher than that for prostate or colon cancer. Prostate cancer searches are not higher in September (prostate CAM), but yearly peaks are seen in Canada in November, corresponding to the “Movember” campaign. Colon cancer searches peak in March (colon CAM) in the U.S.; breast cancer searches universally peak each October (breast CAM). Data from specific CAMs vs. all other months are presented in Table 1. Among screening tests, only “mammogram” was searched significantly more often in breast CAM in the U.S.

Conclusions:

The Movember campaign, but not prostate CAM, appears to have traction in influencing disease-specific internet searches in Canada, but not elsewhere; neither affects searches regarding PSA testing. Breast CAM is universally associated with higher internet search volume for the disease and for mammography in the U.S. Cancer organizations should note these results as an opportunity to reach patients who are already online in significant numbers.

Table 1.

MP-07.13.

Country	Awareness month	ANOVA p value	Number of months CAM search volume > other months	ANOVA p value	Number of months CAM search volume > other months
		Breast cancer		Mammogram

Canada	October	<0.001	11	<0.001	2 (2005–14)
USA	October	<0.001	11	<0.001	11
Australia	October	<0.001	11	0.004	2 (2007–14)
UK	October	<0.001	11	<0.001	7 (2005–14)

		Prostate cancer		PSA test

Canada	September	<0.001	0	0.042	0 (2006–14)
USA	September	<0.001	0	0.006	1
Australia	September	<0.001	3	0.401	0 (2010–14)
UK	September	<0.001	0	0.065	0 (2007–14)
Canada	November	<0.001	9	0.042	0 (2006–14)
USA	November	<0.001	1	0.006	0
Australia	November	<0.001	3	0.401	1 (2020–14)
UK	November	<0.001	4	0.065	0 (2007–14)

		Colon cancer		Colonoscopy

Canada	March	<0.001	0	<0.001	0
USA	March	<0.001	11	<0.001	5
Australia	June	<0.001	0	<0.001	0 (2005–14)
UK	April	0.008	1	0.008	0

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S75–S76.

MP-07.14: Paternal family history of prostate cancer among patients undergoing radical prostatectomy across Quebec is associated with better pathologic parameters and greater familial breast cancer

Dina Hamd ¹, Simone Chevalier ^1,², Ginette McKercher ², Fadi Brimo ¹, Mathieu Latour ³, Bernard Têtu ⁴, Nadia Ekindi-Ndongo ⁵, Eleonora Scarlata ¹, Saro Aprikian ¹, Fred Saad ³, Louis Lacombe ⁴, Michel Carmel ⁵, Armen-G Aprikian ^1,²

Abstract

Introduction and Objectives:

Men with a positive family history of prostate cancer (PCa) have a higher risk of developing prostate cancer. Several hereditary diseases have a higher incidence in Quebec due to the “founder effect.” The relationship of degrees of familial PCa, clinicopathologic parameters, and outcome is unclear. Our objective was to examine the association of family history in the PROCURE cohort of PC patients with clinicopathologic parameters.

Methods:

1856 PCa patients scheduled for radical prostatectomy in four Quebec teaching hospitals (2007–2012) filled a self-administered and then verified questionnaire as part of enrolment in PROCURE Biobank.

Results:

686 men (36.4%) reported a family history of PCa, including father (n=347), brothers, grandfathers, uncles, and cousins. The 347 patients with paternal PCa (pPCa) were diagnosed at an earlier age compared to no pPCa (61.5 vs. 62.5; p=0.0007). Patients with pPCa had better clinicopathologic parameters: 2.0% vs. 17.4% had a serum prostate specific antigen (PSA) level >10ng/ml, less extraprostatic extension (30.3% vs. 35.7%), and less seminal vesicle invasion (8.6% vs. 11.2%). Patients with pPCa had one or more family members with PCa (41% vs. 22%) and came from a smaller family (three siblings vs. five; p<0.0001). Brothers accounted for 50% of these PCa. Patients with pPCa reported more breast cancer (BrCa) (27.0% vs. 18.4%) in their family. More than 80% had up to two family members with BrCa with more mothers affected (41.1% for pPCa vs. 30.9% for no pPCa). Patients with pPCa who had additional family members with PCa had lower PSA (5.8 vs. 9.3 ng/ml; p=0.033), extraprostatic extension (25.2% vs. 33.8%), seminal vesicle invasion (5.6% vs. 10.8%), and reported more BrCa (32.2% vs. 24.0%).

Conclusions:

Paternal family history of PCa in the PROCURE cohort of Quebec men undergoing radical prostatectomy, was associated with better clinicopathologic parameters, and additional family members with PCa and BrCa.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S76.

UP-07.01: Differential regulation of mechanistic target of rapamycin pathways in hormone-dependent and independent prostate cancer

Premal Patel ¹, Andrea Dypiangco ², Arbind Dubey ³, Darrel E Drachenberg ¹, Anuraag Shrivastav ²

Abstract

Introduction and Objectives:

Mechanistic target of rapamycin (mTOR), which is the downstream target of PI3K/Akt pathway, is a complex central hub for various signaling pathways regulating protein synthesis, cellular differentiation, proliferation, and transformation. In prostate cancer (PCa), alterations in the signaling members of the PI3K/Akt/mTOR pathway have been reported in 42% of primary and 100% of metastatic PCa. The mTOR signaling is often dysregulated in human cancer, including PCa and has been pursued as a therapeutic target. The activation of PI3K/Akt/mTOR pathway has been demonstrated in castration-resistant prostate cancer (CRPC). N-myristoyltransferase (NMT) catalyzes myristoylation of proteins that regulate mitogenic pathways. We previously demonstrated that activation of Akt1 leads to phosphorylation of NMT1, which attenuates its activity. However, the mechanism of regulation of NMT by activated Akt is not known. Therefore, we investigated whether NMT is mediated via mTOR.

Methods:

To determine differential alteration in PI3K/Akt/mTOR pathway in hormone-dependent and independent PCa, we treated LNCaP (hormone-dependent), PC3, and Du145 (both hormone-independent) PCa cells with metformin and/or rapamycin. Both metformin and rapamycin inhibit mTOR through different effectors.

Results:

We demonstrate high levels of NMT activity in hormone-independent cell lines as compared to our hormone-sensitive cell line. There was increased expression of pAMPK in PC3 cells treated with rapamycin and metformin and rapamycin.

Conclusions:

We observed differential effect of metformin and rapamycin on hormone-independent and dependent PCa cells. We also report for the first time that NMT is a downstream target of mTOR in PCa. Together, our data suggest PI3K/Akt/mTOR pathway is differentially regulated in hormone-dependent and independent PCa cells and regulation of NMT by mTOR may provide further insight into the pathogenesis and progression of PCa.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S76–S77.

UP-07.02: What false negative rate are active surveillance patients willing to accept in order to avoid prostate biopsy?

Rashid Sayyid ¹, Dharmendra Dingar ¹, Erik Yao ², Taylor Thorburn ³, Joshua Diamond ⁴, Karen Hersey ¹, Antonio Finelli ¹, Alexandre Zlotta ¹, Robert J Hamilton ¹, Girish S Kulkarni ¹, Michael A Jewett ¹, Neil E Fleshner ¹

Abstract

Introduction and Objectives:

Prostate biopsies are associated with significant complications. Imaging and blood/urine-based non-invasive tests are being developed in order to better predict disease grade and volume. We conducted a survey among active surveillance (AS) patients (and their partners) to determine what thresholds of false-negative (FN) they would accept in such a tests(s) to avoid biopsies, and their willingness to pay out-of-pocket for these tests if they were not reimbursed by our public healthcare system.

Methods:

We developed a validated eight-question survey for men and their partners to determine the acceptable FN rate for non-invasive test(s) and their acceptable out-of-pocket cost should they not be reimbursed by third-party payers. All patients had confirmed prostate cancer and were managed by AS at our centre. Data was collected on age, level of education, annual income, marital status, number of prior prostate biopsies in order to determine if these covariates were associated with responses.

Results:

130 men completed the survey (number of spouses 23). 90.6% of patients were comfortable with the concept of a non-invasive test in place of a prostate biopsy. 82.8 % would accept a test(s) with a FN rate of 1%, while 64.8% would accept a test(s) with a FN rate of 5%. Significantly, 10% of patients were not comfortable with any alternative to biopsy.

Demographics were not associated with response, and spousal responses were similar to those of patients. As for expenditures, 9% would not pay out-of-pocket, while 16.4% would pay $1000 or more and 26.5% $500 or more.

Conclusions:

Our results suggest that the vast majority of patients would accept a non-invasive test in place of a transrectal ultrasound (TRUS) prostate biopsy, however it appears that FN rate of 1% will need to be achieved. Given the limitation of current imaging/biomarkers, periodic prostate biopsy will be needed in routine management of men on AS for low-risk prostate cancer.

Table 1.

UP-07.02. Patient’s false negative rate threshold for non-invasive test(s)

False negative rate threshold		Valid percent	Cumulative percent
Valid	80 times out of 100, the biopsy could be safely omitted	13.3	13.3
	90 times out of 100, the biopsy could be safely omitted	21.1	34.4
	95 times out of 100, the biopsy could be safely omitted	30.5	64.8
	99 times out of 100, the biopsy could be safely omitted	18.0	82.8
	995 times out of 1000, the biopsy could be safely omitted	7.8	90.6
	I am not comfortable with a non-invasive test in place of prostate biopsy	9.4	100.0
	Total	100.0
Missing	System
Total

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S77.

UP-07.03: Does surgical delay for radical prostatectomy affect patient pathological outcome: A retrospective analysis on 1258 patients

Marc Zanaty ^1,², Mansour Alnazari ^1,², Emad S Rajih ^1,², Abdullah M Alenizi ^1,², Pierre-Alain Hueber ¹, Assaad El-Hakim ^1,², Kevin C Zorn ^1,²

Abstract

Introduction and Objectives:

Given limitations to resources in a publically funded healthcare system, we sought to assess the impact of surgical wait time (SWT) to robot-assisted radical prostatectomy (RARP) on final pathological outcome.

Methods:

Retrospective review of 1258 patient records operated by RARP performed between 2006 and 2015 was conducted. SWT was defined as period from prostate biopsy to surgery. Primary outcome was the impact on postoperative Cancer of the Prostate Risk Assessment (CAPRA) score, which has been well-documented to correlate with biochemical recurrence, cancer-specific and overall survival. Patients were stratified according to D’Amico risk categories. Univariate and multivariate analysis with a generalized linear model was used to evaluate the effect of SWT and other predictive factors (age, body mass index (BMI), biopsy Gleason score, clinical stage and, percentage of positive cores) on pathological outcome in each risk group and on the overall sample.

Results:

835 patients were eligible for analysis. High and intermediate D’Amico risk categories were grouped together in the same strata, due to the limited number of men (55) in D’Amico high-risk category. Mean SWT was significantly different between the two groups: 162.9 days in high/intermediate-risk group vs. 179.3 in low-risk group (p=0.009). After stratification on D’Amico risk group, SWT did not significantly affect postoperative CAPRA score on univariate analysis in both strata. In multivariate analysis, SWT was significantly correlated to CAPRA score only in high/intermediate-risk group (p=0.049). There was no correlation in multivariate analysis in the low-risk group and in the overall cohort. Predictors of higher CAPRA score in the multivariate model were: older age (p=0.030), biopsy Gleason score (p<0.001), percentage of positive cores (p=0.001), clinical stage (p<0.001), and SWT (p=0.049).

Conclusions:

In the present study, evaluating SWT for Canadian men in a publically funded system, increased delay for surgery could affect the pathological outcome. Further studies are needed to give more solid proof and assess the impact of SWT on biochemical-free survival, cancer-specific survival, and disease-free survival.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S77.

UP-07.04: Prostate cancer patients’ met and unmet supportive care needs: A cross-sectional, population-based survey

Jackie Bender ¹, Deb Feldman-Stewart ², Christine Tong ², Howard Pai ³, Jacky Au ¹, Michael D Brundage ², John Robinson ⁴, Hannah Carolan ⁵, LK Joseph Chin ⁶, Joyce Davison ⁷, Arminee Kazanjian ⁸

Abstract

Introduction and Objectives:

To determine the met, unmet, and total supportive care needs of prostate cancer patients.

Methods:

Surveys were conducted in three provinces (BC, AB, SK) from 2014–15, using a modified Dillman mail-survey methodology. A random sample of ~55% of men in each provincial registry diagnosed with prostate cancer in the last half of 2012 was surveyed. Supportive care needs were assessed using a modified version of the 34-item Supportive Care Needs Survey, supplemented with the eight-item Prostate Cancer Survey.

Results:

Response rates ranged from 46–55% (n=1007). Overall mean age was 69 years. Most were either receiving followup monitoring after active treatment (49%) or were on active surveillance or watchful waiting (22%). Respondents reported more met (M=7.7, SD=9.1) than unmet needs (M=3.8, SD=6.2), t (937)=10.9; p<0.001. In order of frequency, domains of need (based on average frequency of reported total met or unmet need) were: sexual (41%), health system and information (39%), psychological (25%), care and support (24%), prostate cancer specific (21%) and physical and daily living (19%). Top five met needs were being informed about test results as soon as possible (45%), being informed that the cancer is under control (37%), being treated as a person (34%), being informed about benefits and side effects of treatments (33%), and being informed about the things one can do to help get well (32%). Top five unmet needs were related to sexual feelings (24%), changes in sexual relationships (23%), perceived loss of manhood (21%), uncertainty about the future (17%), and being given information about sexual relationships (17%). Respondents who received active treatment (surgery, external beam radiation, or brachytherapy) reported more total (met or unmet) needs (M=16.3, SD=15.1) than those who received surveillance or watchful waiting (M=10.5, SD=13.6) (t (890)=3.78; p<0.001), but did not report significantly more unmet needs (t (890)=1.58; p<0.12).

Conclusions:

A considerable proportion of prostate cancer patients have unmet supportive care needs. Most unmet needs relate to changes in sexual feelings or sexual relationships, and uncertainty about the future. Interventions are needed to assist prostate cancer patients in adapting to sexual changes, address their information needs, and support their psychological well-being.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S77.

UP-07.05: Castration-resistant prostate cancer patients in Quebec: Medication use in the last year of life

Alice Dragomir ¹, Marie Vanhuyse ², Fabio Cury ³, Armen-G Aprikian ¹, Jason Hu ¹

Abstract

Introduction and Objectives:

The current management of metastatic castration-resistant prostate cancer (mCRPC) has become very complex with the approval of several new drugs. The study objective was to describe medication use in the last year of life of patients dying of prostate cancer in Quebec.

Methods:

The study cohort consists of patients who received medical or surgical castration, became castration-resistant and died between January 2001 and July 2013 in Quebec. CRPC was defined as patients who received chemotherapy, abiraterone (Abi), palliative radiotherapy, bone-targeted therapy (BTT) or an anti-androgen. For each patient in the study cohort, medication use (CRPC-related and overall) was identified from the RAMQ pharmaceutical database by 12-, six-, three- and one-month periods prior to death.

Results:

The cohort consists of 1692 patients who died of CRPC in the study period. 767 (45.3%) and 169 (10.0%) patients had received BTT and Abi, respectively. Of the patients receiving BTT at any time, 54.4%, 73.7%, 80.8% and 89.8% received a prescription in the one-, three-, six- and 12-month period before death, respectively. Among the patients receiving Abi at any time, the corresponding figures were: 49.1%, 65.7%, 79.9%, and 96.5%, respectively. The percentage of patients receiving androgen-deprivation therapy (ADT) in the one-, three-, six- and 12-month period before death were: 10.7%, 59.6%, 74.8%, and 83.6%, respectively. The median number of prescriptions per month was 7.1 (interquartile range (IQR 4.6–10.1) in the last 12 months of life, 7.8 (IQR 5.1–11.3) in the last six months, 8.7 (IQR 5.1–12.8) in the last three months, and 1.7 (IQR 0–5.7) in the last month of life.

Conclusions:

In the CRPC group, a large proportion of patients maintained their medications in their last months of life. Persistent ADT, BTT, and Abi during the last few months of life are common, associated with significant costs, yet debatable benefit.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S78.

UP-07.06: TrueNTH peer navigation for prostate cancer patients and their caregivers: Initial discovery and lessons learned

Arminee Kazanjian ¹, Shimae Soheilipour ¹, Lisa Parvin ¹, Nandini Maharaj ¹, Aaron Miller ², Parminder Flora ², Jackie Bender ²

Abstract

Introduction and Objectives:

As part of TrueNTH initiatives, we are developing a program of peer navigation to improve prostate cancer (PCa) patients’ experience of care. PCa survivors are trained as peer providers of informational and emotional support services. The discovery phase aims to review the status and challenges of existing peer-support programs in order to define the TrueNTH intervention.

Methods:

A systematic review of published literature, an environmental scan, and semi-structured interviews of stakeholders were undertaken.

Results:

Only six of the 34 Canadian programs are peer-led and none are specific to PCa patients, suggesting the existence of a care gap in this group. Identified peer-led programs provide one-time connects (single phone call or visit) or short-term communication. Evaluation of outcomes show high satisfaction and acceptability rates among the majority of cancer patients who participated in peer-support programs. Two one-on-one peer-support intervention studies were specific to PCa, one indicated improvement in psychological distress from baseline and another identified lower depression and higher self-efficacy for the intervention group. Our interviews with healthcare professionals (HCPs) found positive and supportive perspectives to peer navigation for PCa patients. The best point of entry is suggested to be immediately after diagnosis. HCPs believe anything that helps patients make more informed and considered decisions is beneficial to clinical practice. A well-designed training program for peer navigators is necessary for provision of appropriate personal support to PCa patients.

Conclusions:

Drawing from available resources and the literature, well-trained and experienced cancer survivors provide cognitive and emotional support to cancer patients to help reduce the psychosocial burden of cancer. Our intervention will provide a unique opportunity for PCa patients, matched with peers based on their individual preferences and communication needs, move forward through their cancer journey in a supportive environment.

Footnotes

Funded by Prostate Cancer Canada through Movember Foundation. (http://au.movember.com/programs/prostate-cancer).

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S78.

UP-07.07: Real-world experience of degarelix, a luteinizing hormone-releasing hormone antagonist in prostate cancer

Evgeny Sadikov ¹, Arbind Dubey ¹, Asim Amjad ¹, Rashmi Koul ¹, Nelson Leong ¹, Wojciech Dolata ¹, Miroslav Jancewicz ¹, Vamsee Torri ¹, Patricia Tai ¹

Abstract

Introduction and Objectives:

Luteinizing hormone-releasing hormone (LHRH) antagonists showed remarkable response in trials. There are few case series outside clinical trials. This is the first report in a Canadian community setting.

Methods:

Data from patients in electronic medical records were entered and analyzed. The primary outcome is response rate.

Results:

From January 2011 to April 2015, degarelix was recommended to 176 patients. Seven patients declined due to drug interaction, comorbidities, or inconvenience. The remaining patients were categorized as Group Adjuvant (27), Biochem (49, asymptomatic prostate-specific antigen (PSA) relapse), Met (74), and Primary (19 primary treatment for non-metastatic disease). Group Biochem had a PSA response of 80% (20/25 evaluable patients) with first-line degarelix and 62% (8/20) after failing LHRH agonist with/without anti-androgens; while group Met had a 76% (29/38) and 28% (7/25) response, respectively. 25 patients were given degarelix monotherapy initially and at time of PSA progression, 21 responded when bicalutamide was added. Some patients have multiple side effects, which mainly included 13 local pain, three local swelling, eight fever/chills, five rashes, five hot flashes, and one pulmonary embolism (possibly related). There were no other documented cardiovascular complications. There were 24/133 (18%) patients requested to stop the drug due to side effects, without any supportive medications to prevent or treat them. However, only 1/22 (4.5%) patients stopped degarelix if given Benadryl, Tylenol, topical lidocaine or steroid, and/or dexamethasone 0.5–1 mg. Patients with non-severe reactions were compliant to continue after physician explanation of the superiority of degarelix over LHRH agonists.

Conclusions:

The addition of an anti-androgen to degarelix as total androgen blockade improves its effectiveness. Improved communication with patients and family doctors, and supportive medications can help patients to stay on degarelix longer.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S78.

UP-07.08: Feasibility and early experience of a multidisciplinary prostate cancer clinic at a community hospital

Sarah Canning ¹, Rhona Schaeffer ¹, Judy Grant ¹, Sarah Sparks ¹, Alvaro Ramirez ¹, Rajiva Singh ¹, Paul Martin ¹

Abstract

Introduction and Objectives:

Patients with prostate cancer represent a diverse patient population with often complex medical needs. Treatment options for patients in all disease states have expanded in the last several years. Not all patients have ready access to a tertiary care cancer centre. We sought to assess the feasibility of a dedicated multidisciplinary prostate cancer clinic at a community hospital and to assess the impact of the clinic on cost and quality of care.

Methods:

The planning, development, and early experience of the prostate cancer clinic are described. Data was prospectively collected during the initial six months of clinic operation. Clinic volumes, patient satisfaction, and patient characteristics, such as disease state and Eastern Cooperative Oncology Group (ECOG) status, are presented. Patient use of hospital resources and impact on hospital revenue is also described.

Results:

During six months of the clinic, there were 602 patient visits. 374 unique patients were seen; 118 patients had multiple visits to the clinic. Patients with biochemical failure represented 17% of visits. Patients with metastatic disease or castrate-resistant disease represented 32% of visits. 17% of patients had ECOG scores of 2–4. 22% of the visits involved use of the hospital outpatient laboratory. 45% of visits involved use of the hospital outpatient pharmacy. The use of the hospital pharmacy led to $29 216 in additional hospital revenue, as well as direct savings for many patients. Community support for this program has resulted in $80 000 in donations through the hospital foundation. Wait times for surgery were within provincial targets 100% of the time. Patient satisfaction was high, with 100% of patients reporting the care they received as positive.

Conclusions:

The creation of a dedicated prostate cancer clinic at a community hospital is feasible and offers several potential advantages to the patient, clinician, and institution.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S78–S79.

UP-07.09: Association between obesity and pathologic upgrading in localized prostate cancer

Christopher H Wu ¹, Jen Hoogenes ¹, Lisa Patterson ², Bobby Shayegan ¹

Abstract

Introduction and Objectives:

Obesity is an increasingly prevalent health concern worldwide. Studies have tested the association between obesity and prostate cancer with conflicting results. Obesity (body mass index (BMI) of ≥30 kg/m²) has been linked to higher prostate cancer incidence, grade, risk of biochemical recurrence, and cancer-specific mortality. Gleason score on biopsy remains one of the strongest prognostic indicators for predicting prostate cancer aggressiveness. Gleason score upgrading (GSU) rates of up to 57% have been reported. As such, there remains a significant risk of undertreating prostate cancer using the biopsy Gleason score alone. Identifying GSU risk factors is an increasingly important issue. A paucity of data exists that address the risk of GSU and obesity.

Methods:

We retrospectively analyzed the records of a consecutive series of men who underwent robot-assisted radical prostatectomy (RARP) a single academic tertiary centre. Patient age, preoperative prostate-specific antigen (PSA), biopsy and pathological Gleason scores, and prostate weight were analyzed against BMI.

Results:

204 patients met the inclusion criteria. Of this patient population, by using calculated BMI, 37% were obese. No significant difference in the age at surgery (61.7 vs. 62.0 years; p=0.84) or PSA level (8.06 vs. 10.04 ng/ml; p=0.14) was found between groups. However, prostate weight (51.0 vs. 56.9 g; p=0.04) was larger in the obese group. No difference was found in the rate of pathologic upgrading in obese vs. non-obese patients (27.5% vs. 33%; p=0.52).

Conclusions:

In patients undergoing RARP for clinically localized prostate cancer, in our sample obesity was not associated with a higher rate of pathologic upgrading. These results contribute to the paucity of existing data on whether obesity is a significant contributor to pathologic upgrading. Our study suggests that obese patients undergoing RARP are not more likely to have aggressive prostate cancer. As data entry is ongoing, we anticipate have over 500 cases for further evaluation.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S79.

UP-07.10: The androgen-deprivation therapy educational program: A Canadian True NTH initiative

John Robinson ¹, Richard J Wassersug ², Lauren M Walker ^1,³, Erik Wobowo ², Andrew Matthew ⁴, Deborah L McLeod ⁵

Abstract

Introduction and Objectives:

Androgen-deprivation therapy (ADT) is commonly used to treat prostate cancer, but has many adverse effects that can directly impair patients’ quality of life and, indirectly, that of their intimate partners. In five Canadian cities, we offer a program on how patients and their partners can stay physically and emotionally healthy and co-supportive when the patient is on ADT.

Method:

Patients recently prescribed ADT and their partners attend a 1.5-hour class and receive the book Androgen-Deprivation Therapy: An essential guide for men with prostate cancer and their partners (Wassersug et al., 2014). Attendees learn strategies for managing ADT side effects and use goal-setting exercises to make beneficial lifestyle adjustments to help manage ADT side effects. To evaluate the effectiveness of the educational program, participants complete questionnaires before attending the class and again 2–3 months later. The questionnaires assess: 1) ADT side effect frequency and bother; 2) self-efficacy in side effect management; 3) physical activity; and 4) relationship adjustment.

Results:

As of December 2015, 232 patients and 150 partners have attended the program in Halifax, Toronto, Victoria, Vancouver, and Calgary. 86 participants consented to participate in the evaluation of the ADT Educational Program. Participant feedback has been overwhelmingly positive.

Conclusions:

The ADT Educational Program is becoming usual care at these centres. It remains to be seen how effective the program is in limiting the bother from ADT side effects and helping couples maintain strong relationships. An online version of the program will soon be available for patients across Canada.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S79.

UP-07.11: Quality assessment of the Canadian Prostate Cancer Biomarker Network platform using the validated prostate cancer biomarker nuclear factor-kappa B p65

Veronique Ouellet ¹, Andree-Anne Grosset ¹, Gabriela Fragoso ¹, Véronique Barrès ¹, Nathalie Delvoye ¹, Mathieu Latour ¹, Dominique Trudel ¹, Armen-G Aprikian ², Alain Bergeron ³, Fadi Brimo ², Robert Bristow ⁴, Simone Chevalier ², Darrel E Drachenberg ⁵, Ladan Fazli ⁶, Neil E Fleshner ⁴, Martin E Gleave ⁶, Pierre Karakiewicz ¹, Laurence H Klotz ⁷, Louis Lacombe ³, Jean-Baptiste Lattouf ¹, Theodorus van der Kwast ⁴, Anne-Marie Mes-Masson ¹, Fred Saad ¹

Abstract

Introduction and Objectives:

The Canadian Prostate Cancer Biomarker Network (CPCBN) is a program that gathers researchers from several institutions from four different Canadian provinces. This network assembled a validation tissue-microarray (TMA) resource composed of 1508 patients treated by radical prostatectomy (RP) separated within test-TMA and full TMA series. This richly annotated resource is available for prostate cancer researchers who wish to access a large cohort to validate their prognostic biomarkers.¹ Over the last decade, we and others have uncovered a robust association between the nuclear localisation of nuclear factor-kappa B (NF-kB) p65, prostate cancer aggressiveness, and biochemical recurrence (BCR).²^,³ Thus, for quality assurance, the CPCBN series was challenged for p65 expression analysis.

Methods:

Automated immunohistochemistry staining of p65 was performed using the CPCBN test-TMAs. This test series contains a minimum of three cores of tumour tissues and two cores of adjacent benign tissues from 250 RP specimens. Two independent observers scored percent of nuclear staining. Statistical analyses were performed using SPSS software.

Results:

By Kaplan-Meier analysis, we validated the significant association between an increase in nuclear frequency of NF-kB p65 and biochemical relapse (log rank, p=0.05, cutoff of 3%) while Cox regression analyses showed a trend (dichotomized p65: p=0.06, Exp(B) 1.58, 95% CI 0.99–2.53). Nuclear frequency of p65 was also associated with increase risk of developing bone metastasis (Cox regression, p=0.03, Exp(B) 1.06, 95% CI 1.006–1.117), although this will need to be confirmed on a larger cohort.

Conclusions:

Our study recapitulates previous observation linking NF-kB p65 with disease progression using a large cohort of Canadian men and also highlight its role as a predictor of bone metastasis.

References

1. http://www.tfri.ca/en/research/translational-research/cpcbn.aspx. Accessed April 21, 2016.
2.Gannon PO, Lessard L, Stevens LM, et al. Large-scale independent validation of the nuclear factor-kappa B p65 prognostic biomarker in prostate cancer. Eur J Cancer. 2013;49:2441–8. doi: 10.1016/j.ejca.2013.02.026. [DOI] [PubMed] [Google Scholar]
3.Labouba I, Le Page C, Communal L, et al. Potential cross-talk between alternative and classical NF-κB pathways in prostate cancer tissues as measured by a multi-staining immunofluorescence co-localization assay. PLoS One. 201510:e0131024. doi: 10.1371/journal.pone.0131024. [DOI] [PMC free article] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S79–S80.

UP-07.12: Describing perspectives of healthcare professionals about active surveillance

Margaret Fitch ¹, Kittie Pang ¹, Veronique Ouellet ², Simone Chevalier ³, Darrel E Drachenberg ⁴, Antonio Finelli ⁵, Lucie Hamel ³, Jean-Baptiste Lattouf ², Kathy Li ⁵, Maureen Palmer ⁶, Paula Sitarik ⁴, Alan I So ⁶, Simon Sutcliffe ⁷, Simon Tanguay ³, Fred Saad ², Anne-Marie Mes-Masson ²

Abstract

Introduction and Objectives:

Practice of active surveillance (AS) for men with low-risk prostate cancer (PCa) is growing across Canada. This study seeks to gain a deeper understanding of healthcare professionals’ (HCP) perspectives in regards to AS and the factors that influence men’s decision to follow this course of action.

Methods:

Focus groups (n=5) were held with HCP who care for men with PCa and are engaged in conversations about AS. Sessions were conducted in four Canadian provinces within academic hospitals (CHUM and MUHC in Quebec, UHN in Ontario, Cancer Care in Manitoba and VCH in British Columbia). Viewpoints were captured regarding current practice regarding AS, the factors that influence the decision to engage in conversations about AS with patients, and observations about the factors that influence men to elect to follow an AS protocol. A content and theme analysis was performed on the verbatim transcripts from the sessions.

Results:

48 HCPs participated in the focus groups and included family physicians, urologists, surgeons, and radiation oncologists. Most described thinking about PCa on a continuum from low-risk to high-risk and saw the need to tailor their recommendations for AS to men based on several factors: status of the disease, patient comorbidity, and perception of the person’s ability to cope. There was broad support for the practice of AS, but little consensus about age being a determining factor in its practice, definitive categorization of marginal patients, the ideal protocol for AS, protocols for long-term followup of men on AS, and AS practices beyond academic centres. Variation was evident in the actual explanations provided and the processes used to inform men about AS.

Conclusions:

Currently, there are various AS protocols in place across Canada. This is especially true after the initial year of surveillance. Men need to have tailored approaches to their surveillance and clear explanations to make informed decisions about following this approach.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S80–S81.

UP-07.13: Age at diagnosis and natural history of stage IV prostate cancer: A population-based analysis

Mounsif Azizi ^1,², Ioana Popa ^1,², Malek Meskawi ^1,², Pierre Karakiewicz ^1,²

Abstract

Introduction and Objectives:

There are few data regarding the impact of age on the natural history of stage IV prostate cancer (PCa). To address this limitation, we examined the relationship between age at diagnosis and the rates of single vs. multiple metastatic sites in patients with metastatic PCa.

Methods:

Patients with metastatic PCa were abstracted from the Nationwide Inpatient Sample (1998–2010). Most common metastatic sites within the entire population were described. Stratification was performed according to the presence of single or multiple (≥ 2 sites) metastases. Additionally, age at diagnosis was stratified into four groups: ≤60, 61–70, 71–80, and >80 years. Cochran-Armitage trend test and multivariable logistic regression tested the relationship between age and the rate of multiple metastatic sites.

Results:

74 826 patients with metastatic PCa were identified. The most common metastatic sites were bone (84%), distant lymph nodes (11%), liver (10%), lung (9%), and brain (3%). Overall, 18% of patients had multiple sites involved. The average age of individuals with multiple vs. single metastatic sites was 72.6 and 74.3 years (p<0.001), respectively. After age stratification, the rate of patients with multiple metastatic sites decreased with increasing age: 21%, 21%, 19%, and 15% for patients aged ≤60, 61–70, 71–80, and >80 years (p<0.001), respectively. These results were confirmed in patients with bone, liver, lung, and brain metastases (all p< 0.01).

Conclusions:

The proportion of patients with multiple metastatic sites is higher in younger patients. These findings are similar to studies focusing on other urological malignancies, suggesting that younger individuals are more likely to present with more aggressive disease phenotype.

Table 1.

UP-07.13. Descriptive characteristics of patients diagnosed with metastatic prostate cancer, nationwide inpatient sample, 1998–2010

	Overall	≤60 years	61–70 years	71–80 years	>80 years	p value
No. of patients	74 826	8853	16 885	25 791	23 300
Site of metastases (%)
Bone	63 134 (84.4)	6766 (76.4)	13 605 (80.6)	22 361 (86.7)	20 402 (87.6)	<0.001
Distant lymph nodes	7912 (10.6)	1875 (21.2)	2513 (14.9)	2236 (8.7)	1288 (5.5)	<0.001
Liver	7615 (10.2)	1038 (11.7)	1925 (11.4)	2575 (10.0)	2077 (8.9)	<0.001
Lung	6366 (8.5)	670 (7.6)	1349 (8.0)	2307 (8.0)	2040 (8.8)	<0.001
Brain	2355 (3.1)	347 (3.9)	748 (4.4)	785 (3.0)	475 (2.0)	<0.001
Other^a	4502 (6.0)	560 (6.3)	1148 (6.8)	1528 (5.9)	1266 (5.4)	<0.001
No. of metastatic sites (%)
1	61 095 (81.6)	7030 (79.4)	13 411 (79.4)	20 858 (80.9)	19796 (85.0)	<0.001
≥2	13 734 (18.4)	1823 (20.6)	3474 (20.6)	4934 (19.1)	3503 (15.0)
Race (%)
Caucasian	38 682 (51.7)	3652 (41.3)	7898 (46.8)	13 341 (51.7)	13 791 (50.2)	<0.001
African-American	11 980 (16.0)	1999 (22.6)	3351 (19.8)	4011 (15.6)	2619 (11.2)
Hispanic	4724 (6.3)	812 (9.2)	1244 (7.4)	1577 (6.1)	1091 (4.7)
Other^b	2338 (3.1)	304 (3.4)	449 (2.7)	869 (3.4)	716 (3.1)
Unknown	17 104 (22.9)	2085 (23.6)	3942 (23.3)	5994 (23.2)	5083 (21.8)
CCI (%)
0	51 619 (69.0)	6862 (77.5)	11 664 (69.1)	17 218 (66.8)	15 875 (68.1)	<0.001
1	17 449 (23.3)	1618 (17.1)	3963 (23.5)	6442 (25.0)	5526 (23.7)
2	4852 (6.5)	412 (4.7)	1056 (6.3)	1782 (6.9)	1603 (6.9)
≥3	910 (1.2)	62 (0.7)	202 (1.2)	351 (1.4)	295 (1.3)

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CCI: Charlsonn comorbidity index

^a

Includes small intestine, large intestine, other metastases in the digestive system, kidney, adrenal gland, pleura, mediastinum.

^b

Includes Asian, Pacific Islander, Native American, and other unspecified.

Table 2.

UP-07.13. Multivariable logistic regression analysis predicting the rate of multiple (≥2) metastatic sites dichotomized according to age groups (≤60 vs. >60 years) within the entire population and according to the most common metastatic sites

Site of metastasis	Odds ratio (95% CI)^a ≤60 vs. >60 years	p value
Overall	1.055 (1.05–1.06)	<0.001
Bone	1.32 (1.24–1.40)	<0.001
Distant lymph nodes	0.45 (0.41–0.51)	<0.001
Liver	1.23 (1.05–1.45)	<0.001
Lung	2.47 (1.91–3.18)	<0.001
Brain	1.05 (0.81–1.38)	0.5

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CI: confidence interval

^a

Model adjusted for Charlson comorbidity index, year of diagnosis, hospital region, and race.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S80–S1.

UP-07.14: Patterns of care in castration-resistant prostate cancer: Impact of initial primary treatment

Jason Hu ¹, Armen-G Aprikian ¹, Fabio Cury ², Marie Vanhuyse ³, Alice Dragomir ¹

Abstract

Introduction and Objectives:

Management of castration-resistant prostate cancer (CRPC) has become very complex. Little is known about the impact of initial treatment for prostate cancer on patterns of care in the CRPC phase. Our study aimed to analyze treatment patterns in CRPC in Quebec by initial treatment received.

Methods:

The cohort selected patients with evidence of CRPC from January 2001 to June 2013 from the public healthcare insurance programs (Régie de l’Assurance Maladie du Québec (RAMQ) and Med-Echo databases). Multivariate logistic regression was used to measure associations between initial primary treatment and patterns of care in CRPC, adjusted for many covariates including comorbidities in the one-year period prior to CRPC.

Results:

Our cohort consists of 2898 patients. Initial treatment for prostate cancer was radical prostatectomy (RP) in 713 patients (24.6%), external-beam radiotherapy (EBRT) in 465 patients (16.1%), and androgen-deprivation therapy (ADT) in 1720 (59.4%). Median age at CRPC was 77.0 (72.0–82.0), 75.0 (70.0–79.0) and 74.0 (70.0–79.0) in the ADT, EBRT, and RP groups, respectively. In the CRPC phase, 547 patients received chemotherapy (overall 18.9%; 15.5%, 26.7%, and 22% in ADT, EBRT, and RP groups, respectively), 159 patients received abiraterone (overall 5.5%; 4.1%, 8.0%, and 7.2%, respectively). When adjusted for covariates, RP (OR 1.30, 95% CI 1.06–1.61) was associated with greater use of bone-targeted therapy compared to the ADT group. EBRT was associated with greater chemotherapy use (OR 1.73, 95% CI 1.33–2.25) compared to the ADT group. Both local treatments were associated with increased use of palliative radiation vs. ADT patients (OR EBRT 1.78, 95% CI 1.39–2.28; OR RP: 1.37, 95% CI 1.10–1.71). A significant decrease in usage for all CRPC treatments was observed for older patients (OR age between 0.94 and 0.98).

Conclusions:

In our cohort, the type of initial primary treatment was associated with certain treatment patterns in the CRPC phase.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S81.

UP-07.15: Ten-year trends in prostate MRI use, referral patterns, and clinical utility at the Massachusetts General Hospital

Michelle Kim ¹, Alexander Ryu ³, Garry Choy ², Dicken SC Ko ¹

Abstract

Introduction and Objectives:

Use of prostate magnetic resonance imaging (MRI) is rapidly increasing despite the lack of strong clinical evidence to support its use. We examine trends in prostate MRI use to better characterize the volume of prostate MRI examinations, underlying examination indications, referral patterns, and diagnostic findings.

Methods:

We conducted a retrospective analysis of all prostate MRIs performed between 2005 and 2015 at a single, large-volume, academic institution in the United States. Studies were categorized based on the clinical history provided in the radiology order and study interpretations. Studies missing dates or radiology interpretations were excluded.

Results:

A total of 2273 studies were performed from 2005–2015. Prostate MRIs performed per year were less than 100 prior to 2011 and increased rapidly to over 600 per year in 2015. The top 20% of ordering providers accounted for 91% of all studies ordered. Urologists accounted for the largest number of studies ordered (57.2%), followed by hematologist/oncologists (14.1%), and radiation oncologists (15.1%). The most common indications for ordering a prostate MRI were initial staging/restaging patients who had not undergone treatment and were not on active surveillance (51.1%), rising prostate-specific antigen (PSA) with negative biopsy (18.5%), active surveillance (10.9%), and surveillance following prostatectomy or radiation (7.7%). Age was not significantly different across the different indications. The MRI results revealed positive findings in 28.6%, negative findings in 23.7%, and indeterminate findings in 17.4% of cases.

Conclusions:

This study demonstrates a rapidly rising trend in the use of prostate MRIs despite the absence of established guidelines to support its use. Clear guidelines for prostate MRI use will be necessary, given the rapid trend in use.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S81.

UP-07.16: A pragmatic Canadian study of abiraterone acetate in the community urology setting: COSMiC

Vincent Fradet ¹, Andrew H Feifer ², Darrel E Drachenberg ³, Geoffrey T Gotto ⁴, Ricardo A Rendon ⁵, Robert Sabbagh ⁶, Bobby Shayegan ⁷, Brita Danielson ⁸, Richard W Casey ⁹, Arusha Oloumi ¹⁰, Huong Hew ¹⁰

Abstract

Introduction and Objectives:

A Canadian Observational Study in Metastatic Cancer of the Prostate (COSMiC) is a non-interventional observational study (Phase 4, ClinicalTrials.gov: NCT02364531) specifically designed to examine the use of abiraterone acetate in the community urology setting and to evaluate patient-reported outcomes (PRO). This data will serve to complement existing safety and efficacy information, prompting increased understanding of the castration-resistant prostate cancer (CRPC) patient experience with abiraterone acetate.

Methods:

Functional Assessment of Cancer Therapy Prostate (FACT-P), Montreal Cognitive Association (MoCA) testing for cognitive impairment and evaluation of adverse events (AE) associated with treatment with abiraterone acetate were assessed. Descriptive and basic statistics and univariate analysis were used to summarize categorical and continuous data. Changes from baseline to Week 12 were summarized with an estimate of the 95% confidence interval (CI) for the mean change.

Results:

53 initial patients with the median age of 78.8 (64.0–91.0) for whom data was available for both baseline and Week 12 followup were included in this analysis. Five patients did not complete Week 12 FACT-P data and 18 patients had both baseline and Week 12 MoCA assessments. Comparison of FACT-P total scores did not show a statistically significant change (95% CI for the means −1.0, 6.4]. At baseline, median score for MoCA from 20 patients was 24.9 (range 12–30) with no statistically significant change at 12 weeks (median 23.8; range 3.0–30, 95% CI for differences in the means −2.5, 0.7]. In addition, 39 patients had reported some type of AEs with peripheral edema most commonly reported in six patients (15.4%) and fatigue reported in one patient (2.6%).

Conclusions:

In this preliminary analysis, FACT-P and MoCA assessments did not demonstrate statistically significant changes at Week 12 compared to baseline. There appeared to be no degradation in the functioning (physical, social, emotional, functional or cognitive) after 12 weeks of therapy. In addition, 12-week followup safety evaluation of treatment with abiraterone acetate appears in line with the previously reported Phase 3 clinical trial data,¹ with no new patterns or safety signals identified.

References

1.Ryan CJ, Smith MR, Fizazi K, et al. Abiraterone acetate plus prednisone vs. placebo plus prednisone in chemotherapy-naive men with metastatic castration-resistant prostate cancer (COU-AA-302): Final overall survival analysis of a randomised, double-blind, placebo-controlled phase 3 study. Lancet Oncol. 2015;16:152–60. doi: 10.1016/S1470-2045(14)71205-7. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S82.

MP-08.01: Clinical phenotyping does not identify those with Hunner’s lesions from those without: A call for routine cystoscopy in evaluation of interstitial cystitis/bladder pain syndrome patients

R Christopher Doiron ¹, Victoria Tolls ¹, Karen Irvine-Bird ¹, Kerri-Lynn Kelly ¹, J Curtis Nickel ¹

Abstract

Introduction and Objectives:

Patients diagnosed with interstitial cystitis/bladder pain syndrome (IC/BPS) represent a heterogeneous group of clinical phenotypes. The presence of Hunner’s lesions presents an opportunity for objective classification into those with Hunner’s lesion IC/BPS (classic IC) and those with non-Hunner’s lesion BPS. While currently, a diagnosis of Hunner’s lesion IC/BPS requires cystoscopy, limited data exist suggesting that these subtypes can be distinguished without endoscopic examination based on the degree of bladder-focused centricity and infrequent association with generalized pain conditions.

Methods:

Patients from a prospective, single-centre database of IC/BPS patients who had documented cystoscopic findings were categorized as those with Hunner’s lesion IC/BPS and non-Hunner’s lesion BPS. Their demographics, pain and symptom scores, voiding symptoms, presence of IBS, and clinical UPOINT scoring were comparatively analyzed.

Results:

A total of 469 patients were reviewed. Of those, 359 had documented local anesthetic cystoscopic findings; 44 (12.3%) with Hunner’s lesion IC/BPS and 315 (87.7%) with non-Hunner’s BPS. Patients with Hunner’s lesions were older (p=0.004), had greater urinary frequency (p=0.013), more nocturia (p=0.0004), and higher ICSI scores (p=0.017). There was no difference in number of UPOINT phenotype domains reported, overall UPOINT scores or prevalence of IBS between the groups.

Conclusions:

A subtype of IC with Hunner’s lesions has worse bladder-centric symptoms, but did not have a distinct bladder-centric phenotype. Given the management implications of distinguishing classic IC from non-Hunner’s lesion BPS, we recommend routine cystoscopy with local anesthesia for all patients with a suspected diagnosis of IC/BPS.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S82.

MP-08.02: Prescription of anticholinergic medication following treatment of localized prostate cancer

Ashley R Cox ¹, Brandon Zagorski ², Greg Hosier ¹, Karthik Tennankore ³, Robert K Nam ⁴

Abstract

Introduction and Objectives:

Several small studies suggest prostate cancer treatment, including radical prostatectomy (RP) and radiation (XRT), may be associated with the development of overactive bladder (OAB). The rate of OAB following treatment for prostate cancer has not yet been investigated at the population level. The purpose of this study was to determine the proportion of men who are prescribed anticholinergic medications after being treated for prostate cancer with radiation compared to surgery, as a marker of estimating the proportion of men with OAB following treatment of prostate cancer.

Methods:

We conducted a population-based, retrospective cohort study comparing men treated for localized prostate cancer with XRT to men treated with RP between 1997 and 2012 in Ontario, Canada. Hospital administrative data and data from the Ontario Cancer Registry (OCR) and the Ontario Drug Benefit (ODB) plan were used. The primary outcome was the prescription of an anticholinergic medication (Ach) after the completion of prostate cancer treatment defined as one new prescription and one refill within six months.

Results:

We identified 7571 and 10 401 men treated with RP and XRT, respectively, who met the inclusion criteria. We found a higher rate of Ach prescriptions in men treated with RP compared to XRT (1.55 vs. 1.03 prescriptions per 1000-months). These rates were both significantly higher than the group of matched controls (0.26 prescriptions per 1000-months). A multivariable analysis revealed that men treated with RP were more likely to receive an Ach prescription than men treated with XRT (adjusted hazard ratio of 1.64, 95% CI 1.44–1.87; p<0.001). Other variables associated with Ach prescriptions included: age 70–74 vs. 66–69 (HR 1.22 95% CI 1.07–1.39; p=0.003), prior history of benign prostatic hyperplasia (HR 1.33 95% CI 1.13–1.56; p<0.001) and multiple comorbidities (HR 1.55 95% CI 1.30–1.84; p<0.001).

Conclusions:

Our study found that men undergoing treatment for localized prostate cancer are at an increased risk of receiving an Ach prescription compared to men who are not treated for prostate cancer. Contrary to our hypothesis, we found an increase in the rate of Ach prescriptions following RP compared to XRT. Further research is required to determine the reason for this finding. Possibilities include surgery patients having followup done by a urologist who may be more inclined to prescribe an Ach. Alternatively, men with post-prostatectomy stress urinary incontinence (PPI) may be prescribed an Ach in attempt to minimize leakage while awaiting surgical treatment of PPI.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S82–S83.

MP-08.03: Treatment efficacy in interstitial cystitis/bladder pain syndrome: Do patients’ perceptions match clinical trial data?

Avril J Lusty ¹, Kay Zakariasen ², Nicole Golda ³, Elizabeth Kavaler ², J Curtis Nickel ¹

Abstract

Introduction and Objectives:

Evidence from clinical treatment trials in interstitial cystitis/bladder pain syndrome (IC/BPS) are employed to develop treatment guidelines. Do patients’ perceptions of success or failure of those specific therapies match that of available clinical trial data?

Methods:

1628 adult females from 48 countries with a self-reported diagnosis of IC completed a web-based survey, examining their symptoms, investigations, and therapies. Patients described their perceived outcomes with the therapies they were exposed to. Previously published literature used to develop IC/BPS guidelines supported the clinical trial data outcomes. Patient-reported outcomes were compared to available clinical trial outcomes.

Results:

In order of effectiveness reported in the literature, the best clinical therapies for IC/BPS should be cyclosporine A, amitriptyline, hyperbaric oxygen, PPS plus subcutaneous heparin, botulinum toxin A plus hydrodistension, L-arginine. The following were reported to be of marginal benefit: intravesical Bacillus Calmette–Guérin (BCG), intravesical chondroitin sulfate, and intravesical lidocaine plus sodium bicarbonate. Based on patient-perceived outcomes, the most effective treatments were opioids (405/621; 65.2%), phenazopyridine (390/638; 65.2%), and alkalizing agents (365/660; 55.3%). Intravesical therapies were associated with an overall improvement rate of 39.4% (237/601), but also a 28.3% worsening rate (170/601). Hydrodistension, electrocautery, and urethral dilation were associated with a 27.9% (218/780), 26.4% (32/121), and 22.5% (115/512), improved symptoms, respectively, but also reported worsening in 27.6% (215/780), 16.5% (20/121), and 22.3% (114/512), respectively.

Conclusions:

Patient perceptions of which treatments provide the most success in ameliorating symptoms do not match well with the treatments evaluated or the benefits reported in the literature. Optimal therapy must include the best evidence from clinical research, but should also include real-life clinical practice implementation and effectiveness.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S83.

MP-08.04: Risk factors for urinary tract infection following mid-urethral sling surgery

Humberto Vigil ¹, Ranjeeta Mallick ², Luke T Lavallee ^1,², Rodney H Breau ^1,², Duane R Hickling ^1,²

Abstract

Introduction and Objectives:

Urinary tract infections following mid-urethral sling (MUS) surgery are common. We sought to determine the incidence of and risk factors for urinary tract infection (UTI) following MUS surgery using a validated, multicentre database.

Methods:

A contemporary cohort of patients was reviewed using the National Surgical Quality Improvement Program (NSQIP) database between the years 2006 and 2012. This database captures 30-day postoperative complication data for patients who undergo surgical procedures and uses the Centers for Disease Control (CDC) criteria for symptomatic UTI. The NSQIP database was queried for the procedural code for MUS. Exclusion criteria include male sex, concurrent procedure at time of MUS, American Society of Anesthesiologists (ASA) score ≥4, totally dependent functional status, emergent or non-elective surgery or any prior surgery within 30 days. Adjusted logistic regression analyses were performed to evaluate the effects of individual risk factors and models of interaction.

Results:

8497 females were included. The rate of UTI within 30 days of MUS was 2.95%. The median time to UTI was 13 days (interquartile range (IQR) 7–19). Demographic factors significantly associated with increased risk of UTI include advanced age (OR 1.63 95 % CI 1.19–2.24), ASA (OR 2.07 95 % CI 1.36–3.13) and body mass index (BMI) score (OR 1.79 95 % CI 1.20–2.68), as well as a history of peripheral vascular disease (OR 6.73 95 % CI 2.24–20.2) and steroid use (OR 2.09 95 % CI 1.01–4.32). Surgical factors include prolonged operating room (OR) time (OR 2.28 95 % CI 1.56–3.34), postoperative admission (OR 2.38 95 % CI 1.79–3.17), level of trainee (OR 0.51 95 % CI 0.29–0.91), and trainee involvement (OR 1.54 95 % CI 1.13–2.09). When compared to gynecologists, urologists had a reduced risk of postoperative UTI (OR 0.63 95 % CI 0.49–0.82).

Conclusions:

The risk of UTI post-MUS surgery is lower than previously described. Novel demographic and surgical risk factors for postoperative UTI have been identified and merit further study.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S83.

MP-08.05: Improving access and reducing costs of care for overactive bladder through a multidisciplinary delivery model

Richard J Baverstock ^1,², Kevin V Carlson ^1,², Andrea Civitarese ¹, Trafford Crump ¹

Abstract

Introduction and Objectives:

Overactive bladder (OAB) is a chronic condition requiring regular management and symptom assessment. Patients with lower urinary tract symptoms, such as OAB, are frequently referred to urology. The growing prevalence of OAB is overwhelming urology capacity, causing lengthy wait times and delaying timely access to care. To address this, the vesia OAB multidisciplinary delivery model was introduced in Calgary, Canada in 2010. The overall objectives of this study are to compare the effect of this delivery model on the 1) volume of care for OAB; 2) direct costs to the healthcare system; and 3) number of cystoscopies.

Methods:

Two cohorts of OAB patients were defined for this study. The first represents all OAB patients treated by two urologists in the year prior to establishing the new clinic (2010). The second represents all OAB patients seen by the new clinic in the year after it was established (2012). Health records for both cohorts were linked to administrative data sources. Changes in the number patients treated and types of visits were measured. Costs were measured by the proportional number of visits to ambulatory clinics, emergency rooms, and discharges from hospital. The proportional number of patients treated with cystoscopies was also measured.

Results:

There were a total of 173 visits in 2010 and 1495 visits in 2012. The average number of visits per patient increased 50% between 2010 and 2012, from 1.15 to 1.73. The proportional distribution of patients accessing ambulatory care services significantly (Pearson Chi-square=160.3; p<0.0001) decreased from 81% to 28% between 2010 and 2012, respectively. There was also a significant (Pearson Chi-square=145.5; p<0.0001) reduction in the proportional use of bladder-related emergency care, from 37% to 6% in 2010 and 2012, respectively. Significantly (Pearson Chi-square=6.0; p=0.014), fewer patients were also discharged from hospital, dropping from 6% in 2010 to 2% in 2012. The proportional number of cystoscopies fell from 53% in 2010 to 21% in 2012.

Conclusions:

Developing a multidisciplinary care team for OAB, which includes family medicine doctors as front-line MDs, improves access to care, reduces healthcare costs, and reduces need for costly procedures, such as cystoscopy.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S83.

MP-08.06: Long-term treatment with onabotulinumtoxinA provides consistent and durable improvements in quality of life in patients with overactive bladder

Blair Egerdie ¹, David Ginsberg ², Victor Nitti ³, Angelo Gousse ⁴, Marcus J Drake ⁵, Albert Kaufmann ⁶, Andrew Magyar ⁷, JP Nicandro ⁸, Sidney B Radomski ⁹

Abstract

Introduction and Objectives:

OnabotulinumtoxinA (onabotA) 100 U has been shown to provide consistent, long-term improvements in overactive bladder (OAB) symptoms in patients (pts) who were inadequately managed by anticholinergic medications. Here, we evaluated the effect of long-term treatment with onabotA on the quality of life (QOL) of OAB pts.

Methods:

Pts who completed one of two phase 3 trials were eligible to enter a three-year extension study. Pts requested onabotA retreatment “as needed” for symptom control and had to fulfill prespecified criteria, so the total number of treatments differed for each patient. Results are reported for up to six treatments. Assessments included change from baseline in Incontinence-QOL (I-QOL) total score and proportions of pts who achieved/exceeded the minimally important difference (MID) in I-QOL score (+10 points) after each treatment. Consistency of response over repeat treatments was evaluated by determining whether pts achieved ≥MID after Treatment 1, and then analyzing the proportion who achieved ≥MID for all subsequent treatments.

Results:

829 pts enrolled in the study. Discontinuations due to lack of efficacy and adverse events were 5.7% and 5.1%. After onabotA Treatments 1–6, increases in I-QOL scores were consistently 2–3X MID (range 22.6–28.6) with most pts achieving ≥MID (range 65.2–76.1%). 72.9% of pts who achieved ≥MID after Treatment 1 maintained I-QOL improvements ≥MID in all subsequent treatments. Over one-third (38.3%) of pts who did not achieve ≥MID after Treatment 1 achieved improvements ≥MID in all subsequent treatments. No new safety signals were observed.

Conclusions:

Durable and consistent improvements in QOL were observed with long-term onabotA treatment, with no new safety signals. Pts with clinically meaningful QOL improvements after Treatment 1 had similar improvements in subsequent treatments, while lack of response to Treatment 1 did not preclude positive response(s) in subsequent treatments.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S84.

MP-08.07: Randomized, controlled trial of laser vs. bipolar plasma vaporization treatment of benign prostatic hyperplasia

Robert J Leslie ¹, Thomas A Skinner ¹, Stephen S Steele ¹, J Curtis Nickel ¹

Abstract

Introducation and Objectives:

It remains unknown how vaporization surgery for benign prostatic hyperplasia (BPH) fits into the Canadian medical system. Evolution of competing systems makes it difficult for centres to adopt a single transurethral vaporization system. We compare two technologies to help guide Canadian urologists and hospitals in selecting new prostate treatment technologies.

Methods:

Patients meeting standardized BPH symptom criteria are randomized into a single, blinded, controlled trial comparing Biolitec EVOLE^® laser vaporization to Olympus TURis plasma button vaporization. Primary outcome is cost-effectiveness, with secondary outcomes of clinical efficacy, resection time, surgical team satisfaction, and safety. 60 patients will be randomized to achieve analysis of primary outcome.

Results:

49 patients have been randomized and treated by December 31, 2015 with three-month followup available for 39. Mean age 71 (68.1–73.7) years, mean preoperative International Prostate Symptom Score (IPSS) 24/35 (22.2–26.8), with mean bother 4.7/6 (4.3–5.2). Mean six- and 12-week IPSS was 12 (9.5–14.8) and 10 (7.1–12.2), respectively. Mean surgeon satisfaction 22/25 (20.4–23.1). Mean nursing satisfaction 22/25 (21.3–23.6). Mean surgical time 28 min (24.3–32.8). Two patients were converted to transurethral resection of the prostate (TURP), four patients sought medical care for hematuria, three patients required dilation for urethral or bladder neck stricture, one developed deep vein thrombosis (DVT), one a urinary tract ingection, and one suffered a thermal bladder injury. All 60 patients have been screened and the last 11 will be randomized in January and February 2016, with completion of three-month followup by May 2016 and unblinded analysis completed by June 2016.

Conclusions:

Analysis of blinded data with three-month followup data suggests that while these technologies may achieve a cost-savings and appear to provide significant amelioration of lower urinary tract symptoms (LUTS), there is a definite learning curve in terms of safety considerations. Analysis of the unblinded comparative data in early June will provide insight into the optimal adoption of vaporization technology in Canadian urological practice.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S84.

MP-08.08: Aging out: Experiences with transition to adult healthcare for spina bifida patients in British Columbia

Cyrus Chehroudi ¹, Damian Duffy ², Bev Irwin ³, Andrew E MacNeily ¹

Abstract

Introduction:

Pediatric-to-adult transitional care is a pressing issue for children with congenital anomalies like spina bifida (SB). At BC Children’s Hospital (BCCH), we follow 350 SB patients/year, but have no transitional care model. The goal of this study was to assess urological followup in adults living with SB.

Methods

A 50-question online survey was distributed to graduates of the BCCH SB clinic. The survey incorporated questions on current health status and experience with transition. 40 urologists known to accept graduating SB patients were also surveyed regarding their urological followup, impressions of health outcomes, and transition readiness for SB patients.

Results:

59 SB patients and 15 urologists completed the surveys (response rates 16% and 40%, respectively). The majority of respondents were over age 30 (41%), wheelchair ambulators (66%), and resided in the Vancouver-Fraser area (71%). The most common health concerns were urinary incontinence (71%) and urinary tract infection (UTI, 65%). However, only 47% of respondents saw a urologist at least annually and 30% of those with a self-reported urological issue (incontinence, UTIs, or stones) were not followed by a urologist. Moreover, 32% of patients felt that not seeing a specialist has led to the development of complications, in particular, urological ones. Over half of participants (62%) were dissatisfied with the transition process, whereas only one urologist felt SB patients were not adequately prepared. SB patients listed transportation (44%) and difficulty finding qualified specialists (22%) as the greatest challenges to transition, while urologists cited lack of understanding of the adult healthcare system (57%), transportation (50%), and poor patient understanding of the complications of SB (36%).

Conclusion:

There is an unmet need for urological followup in adults with SB. These vulnerable patients would benefit from a patient-centred multidisciplinary clinic that addresses barriers to care.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S84.

MP-08.09: The impact of urinary tract infections on individuals living with traumatic and non-traumatic spinal cord injury in Canada: Results from the Rick Hansen Spinal Cord Injury Registry Community followup

Lynn Stothers ¹, Blayne K Welk ², Rouzbeh Ghadiri-Tavi ³

Abstract

Introduction and Objectives:

Urinary tract infections (UTIs) are the most frequent urological complication following spinal cord injury (SCI), but the extent of neuro-trauma, socioeconomics, activity levels, quality of life (QoL), and secondary complications related to UTI frequency are unknown. Objectives: 1) delineate association of socioeconomic factors with likelihood of UTI; 2) assess UTI impact on activity level, satisfaction, and QoL; and 3) determine frequency of secondary complications to likelihood of UTI.

Methods:

Rick Hansen Institute SCI Community Survey database of environmental factors, presence/absence of 30 comorbid conditions, Short Form-12 and QoL in 1137 traumatic and 432 non-traumatic injuries. UTI frequency stratification was none; once a year; few times a year; few times a month. Secondary complications were bowel incontinence, constipation, spasticity, and autonomic dysreflexia (AD). Statistics: t-test, cross-tabulations, Chi2 tested significance.

Results:

1124 (73.5%) reported developing at least one UTI within 12 months. Of those, 31% had 12 or fewer years of education, 72.8% had an annual income of ≤$50 000, and 26.3% were living in a rental home, assisted-living, or other long-term care. In 21%, UTI limited activity to a great extent or completely. QoL was reported as bad or very bad in 9%, fair in 27%, and good or very good in 64%. 53% had bowel incontinence, 81.7% constipation, 23.4% spasticity, and 56.3% AD. Individuals with >1 UTI were more dissatisfied with activity levels than individuals without (p<0.05). 38% of those with UTI > or = a few times a month had activity and QoL lower than those with less frequent UTI (p<0.001).

Conclusions:

Socioeconomic factors and secondary complications are independently inter-related with the likelihood of contracting UTI. More frequent UTIs are associated with greater activity limitation, less satisfaction with activity, and lower QoL. Future work to develop a tool identifying those at greatest risk of UTI is warranted.

Acknowledgments

RHI & Ontario Neurotrauma Foundation.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S84–S85.

MP-08.10: Altis^® adjustable, single-incision sling for female stress urinary incontinence: Mid-term efficacy and satisfaction

Melanie Aube-Peterkin ¹, Suzie Adam ¹, Richard Sioufi ², Le Mai Tu ¹

Abstract

Introduction and Objectives:

To evaluate mid-term safety and efficacy of the Altis^® single-incision sling system for the treatment of female stress urinary incontinence (SUI). Altis has been proven safe and effective with a short-term follow-up of 12 months.

Methods:

A prospective trial was performed in two centres for female patients with SUI who had failed conservative therapy. Patients were evaluated preoperatively and postoperatively at three and six months, then yearly. Followup consisted of a questionnaire and a gynecological exam, as well as objective and subjective measures. Objective outcomes consisted of 24-hour pad weight test, daily pad use, and cough stress test. Subjective measures consisted of the Urogenital Distress Inventory-Short Form (UDI-6), Incontinence Impact Questionnaire-Short Form (IIQ-7), and Patient Global Impression of Improvement (PGI-I) questionnaires.

Results:

Between 2009 and 2013, 94 patients received the Altis sling. Mean patient age was 60.3 years. Interim analysis of data was done in 2015. By this time, 18 patients were lost to followup, leaving 76 patients for assessment. Median followup for these 76 patients was 44 months. Median 24-hour pad weight test decreased from 20.4 g (13.5, 74.6 interquartile range (IQR)) at baseline to 0.0g (0.0, 5.0 IQR) at final followup (p<0.0001). Median daily pad use decreased from 2.5 (1.5, 3.5 IQR) to 0.0 (0.0, 1.0 IQR) (p<0.0001). Positive cough stress test was present in 100% of patients preoperatively and was reduced to 17%. Subjectively, median reduction in UDI-6 and IIQ-7 scores were 5.0 (2.5, 9.0 IQR) (p<0.0001) and 12.0 (6.0, 16.0 IQR) (p<0.0001), respectively. 92% (70 patients) indicated that their SUI was “very much better” or “much better” based on the PGI-I. No patient was worsened by the sling. No cases of mesh extrusion were reported. Three patients (4%) experienced transient urinary retention.

Conclusions:

The Altis single-incision sling system is a safe and effective for treatment of SUI, with high patient subjective satisfaction.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S85.

MP-08.11: Intravesical onabotulinumtoxinA injection is safe and efficacious in elderly patients

Kevin V Carlson ^1,², J Matthew Andrews ¹, Ian TS Wright ¹, Andrea Civitarese ¹, Trafford Crump ¹, Richard J Baverstock ^1,²

Abstract

Introduction and Objectives:

Injecting intravesical botulinumtoxinA (BTA) for refractory lower urinary tract conditions is a well-established treatment. While a large proportion of patients requiring such treatment are elderly, little data is published regarding its efficacy and safety in older patients. The objective of this study is to report our results of BTA injection in an elderly population of patients.

Methods:

A retrospective chart review of patients injected between July 20, 2009 (when charts became available via electronic record) and October 30, 2013 was performed to identify patients receiving BTA in our practice who were 70 years or older at the time of injection.

Results:

A total of 330 injections were performed on 110 unique patients with mean age of 80.7 years (75–93). Indications included neurogenic detrusor overactivity (NDO) (22%), idiopathic detrusor overactivity (IDO) (68%), and bladder pain syndrome (BPS) (5%). 5% of these patients presented with other or indeterminate etiology. 23 of the IDO patients in this sample presented with overactive bladder (OAB) after a previous procedure (TVT insertion, radiation or cryotherapy, prostate therapy or Bacillus Calmette–Guérin (BCG) therapy). In the NDO group, 42% were female, compared to 61% of the IDO and 100% of the BPS groups. The majority of patients (68%) were injected under local anesthesia only. The number of BTA treatments ranged from 1–19. 62% of patients received >1 injection while 36% received ≥3, and 14% received ≥6. 96 patients (87%) trialed at least one OAB medication before injection, while 27 patients (25%) had to restart OAB medication at some point during BTA treatment. Overall, 36% discontinued BTA due to death, lack of effect, or change in bladder management. 21% initiated clean intermittent catheter (CIC), while six (5%) performed CIC before BTA treatment, and seven (6%) had indwelling catheters. There were no serious adverse events.

Conclusions:

Intravesical BTA is well-tolerated and safe, even in elderly patients. A moderate number of patients initiated CIC in our blended cohort. Persistence with treatment is high, at 64%, despite the challenging nature of this patient population.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S85–S86.

MP-08.12: Assessment of energy density usage during 180 W lithium triborate laser photo-selective vaporization of the prostate for benign prostatic hyperplasia: Is there an optimal amount of energy density?

Pierre-Alain Hueber ¹, Roger Valdivieso ¹, Christian Meyer ², Malek Meskawi ¹, Abdullah M Alenizi ¹, Quoc-Dien Trinh ², Vincent Misra ³, Matthew Rutman ⁴, Alexis Te ⁵, Bilal Chughtai ⁵, Neil Barber ⁶, Amr Emara ⁶, Ravi Munver ⁷

Abstract

Introduction and Objectives:

The ideal amount of energy delivery during photoselective vaporization of the prostate (PVP) for optimal treatment of benign prostate hyperplasia (BPH) has not been established.¹ The aim of this study is to assess the effect of energy density (kJ/cc) applied on adenoma during treatment on functional outcomes, prostate-specific antigen (PSA) reduction, and complications.

Methods:

After exclusions, a total of 440 patients who underwent Greenlight laser XPS 180 W LBO PVP for the treatment of BPH were retrospectively reviewed. Data was collected from seven different international centres (Canada, United States, United Kingdom, and France). Patients were stratified into four energy density groups (kJ/cc) according to intraoperative energy delivered and prostate volume as determined by preoperative transrectal ultrasound (TRUS): Group 1: <3 kJ/cc; Group 2: 3–5 kJ/cc; Group 3: 5–7 kJ/cc; and Group 4: >7kJ/cc. Energy density groups were chosen arbitrarily. PSA reduction and functional outcomes (International Prostate Symptom Score (IPSS), quality of life (QoL), post-void residual urine volume (PVR), Qmax) were compared at six, 12, and 24 months. Moreover, perioperative complications and retreatment rates were also compared between groups.

Results:

PSA reduction at 24 months post-procedure was 51%, 61%, 79%, and 83% for an energy-density groups of <3, 3–5, 5–7, and >7 kJ/g, respectively (p<0.01). This held true after accounting for baseline confounders. Energy-density was not associated with increased complication rates, including hematuria, stricture formation, incontinence, refractory urinary retention, urinary tract infection, and conversion to transurethral resection of the prostate (TURP). Functional outcomes at two years of follow up were equivalent between groups (p>0.05 for all) and comparable re-treatment rates were observed (p=0.36).

Conclusions:

Increased energy usage per cc of prostate is associated with a more significant PSA reduction (>50%) at six, 12, and 24 months, suggesting increased vaporization of adenoma tissue. However, this did not translate into differences in functional outcomes at two years of followup.

Table 1.

MP-08.12. PSA drop and functional outcomes after XPS180 LBO PVP for BPH at 24 months according to energy usage per cc of prostate

Variables at 24 months	<3 kJ/cc	3–5 kJ/cc	5–7 kJ/cc	≥7 kJ/cc	p value^*
Median PSA drop (%)	51	61	78.8	83.1	0.002
Median IPSS drop (%)	81.8	80.5	81.7	79.1	0.73
Median QoL change (%)	83.3	80	83	75	0.73
Median Qmax change (%)	309.1	233.3	300	425	0.48
Median PVR drop (%)	96.2	95.1	95.5	94	0.86

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IPSS: International Prostate Symptom Score; PSA: prostate-specific antigen; PVR: post-voiding residue; QoL: quality of life; Qmax: maximal urine flow.

References

1.Hueber PA, Bienz MN, Valdivieso R, et al. Photoselective vaporization of the prostate for benign prostatic hyperplasia using the 180 Watt system: Multicentre study of the impact of prostate size on safety and outcomes. J Urol. 2015;194:462–9. doi: 10.1016/j.juro.2015.03.113. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S86.

MP-08.13: Effect of AQX-1125 on urinary bladder inflammation and pain induced by cyclophosphamide in rats, by targeting the SHIP1 pathway

Jennifer Cross ¹, Curtis Harwig ¹, Pat Tam ¹, Judy Toews ¹, Lloyd F Mackenzie ¹

Abstract

Introduction and Objectives:

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic inflammatory syndrome characterized by pain, pressure, or discomfort in the bladder, and accompanied by urinary symptoms of frequency and urgency. AQX-1125, a novel SH2-containing inositol-5′-phosphatase 1 activator with broad anti-inflammatory properties, represents a potential once-daily, oral therapy for IC/BPS. In rats, a single injection of cyclophosphamide (CYP) induces a chemical cystitis with similar features of IC/BPS, including inflammation of the bladder, visceral pain, and an increase in urinary frequency. The aim of this study was to evaluate the effect of AQX-1125 (0.3, 3, and 30 mg/kg doses) on visceral pain, inflammation, and cystometric parameters in acute CYP-induced cystitis in rats.

Methods:

Cystitis was induced in female Sprague Dawley rats by a single intraperitoneal injection (150 mg/kg) of CYP. AQX-1125 was administered once daily. Von Frey testing measured visceral pain at four hours post-challenge and bladders were excised to measure bladder wall thickness, cytokine levels, and to score the extent of edema and hemorrhage.

Results:

AQX-1125 at 0.3, 3, and 30 mg/kg reduced visceral pain, assessed from von Frey 1–60 g, with maximal inhibitions occurring in the 1–6 g range (49%, 95%, and 92%, respectively, as compared to the CYP/vehicle group). The AQX-1125 reduction in visceral pain (von Frey 1–60 g), was the same at 3 and 30 mg/kg (31%), and was comparable to the reference standard ibuprofen (37% at 300 mg/kg). AQX-1125 at 3 mg/kg also significantly decreased the inflammatory parameters of bladder wall thickness and the edema score. At 30 mg/kg, AQX-1125 also showed a positive trend in decreasing the intercontraction interval.

Conclusions:

The novel SHIP1 activator, AQX-1125, is able to decrease visceral pain and bladder inflammation in a rodent model of cystitis. This compelling data supports development of AQX-1125 as an oral, once-daily therapy for IC/BPS.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S86.

MP-08.14: Device survival following primary implantation of the AMS 800 artificial urinary sphincter for male stress urinary incontinence

Faysal A Yafi ¹, Carrie Stewart ¹, Jason Chiang ¹, Premsant Sangkum ², Wayne JG Hellstrom ¹

Abstract

Introduction and Objectives:

The AMS 800TM artificial urinary sphincter (AUS) remains the gold standard for the management of moderate to severe stress urinary incontinence in men. We reviewed the largest database to date to assess device survival following primary implantation.

Methods:

Retrospective data was collected from the AMS 800TM patient information form (PIF) database. Since 1981, 77 512 PIFs for primary AUS implantation performed in the United States were completed. Following exclusion of procedures performed in children and females, and those labeled with an unknown surgical technique, 27 096 AUS cases were included in the analysis. Collected variables were patient age, surgical approach (perineal vs. penoscrotal), number of cuffs (single vs. tandem), and surgeon volume (low (<10 AUS/year) vs. high (≥10 AUS/year)). Measured outcomes included device explantation, device revision, component revision, and time to each event.

Results:

Mean age was 68.6 years (standard deviation (SD) 8.9). AUS insertion was performed by high- and low- volume implanters in 4666 (17.4%) and 22 165 (82.6%) of cases, respectively. Approach was perineal in 18 373 cases (67.8%) and penoscrotal in 8723 cases (32.2%), and a tandem cuff was used in 2224 cases (8.2%). Overall, 5723 cases required either revision or explantation (21.1%). Mean time to device explantation was three years (SD 2.6), any revision 1.8 years (SD 1.9), cuff revision 2.6 years (SD 2.4), pump revision 2.9 years (SD 2.6), and pressure regulating balloon (PRB) revision 2.9 years (SD 2.6). Younger age and penoscrotal approach were associated with higher device explantation and revision rates, while use of a tandem cuff was associated with higher explantation rates. On multivariate analysis, younger age, penoscrotal approach, and use of a tandem cuff, but not surgeon volume, were significant predictors of device explantation and component revision.

Conclusions:

These results provide a general overview on AUS device survival and may serve urologists when counselling patients. Younger age, penoscrotal approach, and use of tandem cuff seem to portend worse outcomes.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S86.

MP-08.15: Evaluation, management, and outcomes of female periurethral masses: A large Canadian series

J Matthew Andrews ¹, Kevin V Carlson ¹, Richard J Baverstock ¹

Abstract

Introduction and Objectives:

Female periurethral lesions are rare and there remains a paucity of literature addressing this subject. We describe our experience involving a large consecutive series of periurethral masses from a single, tertiary urological centre.

Methods:

A prospective case series was maintained from clinical diagnosis to complete followup by a single surgeon. All cystic and solid masses were included. Simple urethral caruncles, urethral prolapse, and iatrogenic masses related to periurethral bulking agents were excluded. All patients underwent history, pelvic evaluation, and flexible cystourethroscopy. Additional imaging was performed on select patients.

Results:

81 women, mean age 40.5 years, were evaluated over a 13-year period (2002–2015). Of these, 64 presented with a palpable periurethral mass and six were referred as result of incidental findings. Complete followup was available for 62 patients following transvaginal excision; median followup 14.5 weeks. 16 patients (20.5%) had anterior vaginal wall cyst; 21 (26.9%) skene’s gland cyst or abscess; 34 (43.6%) urethral diverticulum; seven (9.0%) benign solid lesion. There were no malignancies, however, two cases involved intestinal metaplasia. Of 58 patients who had preoperative imaging, this was accurate in 80.7% and deemed useful for surgical planning in 60.3% of cases. Magnetic resonance imaging (MRI) was useful in 68.6% of cases, with sensitivity 80.0%. Following surgical excision, 91.0% of patients identified a successful outcome. Two recurrences were encountered. Overall complication rate was 10.3%, and highest for cases involving complex urethral diverticulectomies (17.6%).

Conclusions:

Transvaginal excision of female periurethral mass is highly successful, with low risk of recurrence. Urethral diverticulum was the most common finding in our series and was associated with the highest risk of surgical complications. MRI is a valuable tool in preoperative planning of such lesions and displays high sensitivity.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S86–S87.

MP-08.16: Effect of onabotulinumtoxinA treatment for neurogenic detrusor overactivity on the prevention of autonomic dysreflexia following spinal cord injury

Renee Fougere ¹, Mark K Nigro ^1,², Daniel Rapoport ², A Krassioukov ¹, Lynn Stothers ^1,²

Abstract

Introduction and Objectives:

Autonomic dysreflexia (AD) is a life-threatening episodic hypertensive crisis triggered most commonly by the bladder and neurogenic detrusor overactivity (NDO). Objectives: 1) to quantitatively investigate efficacy of 200 U of onabotulinumtoxinA on reducing severity and frequency of AD during urodynamics (UDS) and 24-hour ambulatory blood pressure monitoring (ABPM); and 2) to determine AD and bladder-related quality of life (QoL) changes.

Methods:

Prospective, open-label study of 14 subjects (11 male, three female) with chronic (>1 year post-injury), traumatic spinal cord injury (SCI), age18–65 years, injured at T6 or higher. All completed UDS#1 pre-screening assessment with arterial blood pressure (BP) and heart rate (HR) monitoring. Subjects who experienced AD as per an increase in systolic BP ≥20 mmHg from baseline underwent 24-hour ABPM and completed two validated QoL questionnaires (IQoL and AD-focused QoL). OnabotulinumtoxinA injection 200 U was administered one week following. One-month post-onabotulinumtoxinA, UDS#2, 24-hour ABPM monitoring and validated QoL questionnaires were reassessed.

Results:

During post-onabotulinumtoxinA UDS #2, there was a significant reduction in AD severity as per average systolic blood pressure (SBP) change (Δ) (p≤0.001) and maximum SBP (p≤0.001). During post-onabotulinumtoxinA 24-hour ABPM, there was significant reduction in bladder-related AD severity SBPΔ (p=0.001) and frequency (p< 0.001), as well as overall AD severity (p=0.005) and frequency (p=0.001). Significant improvements were found in AD-related QoL (p=0.0015) and bladder-related QoL (p=0.0005). AD was abolished in 8/14 (57%).

Conclusions:

200 U of intra-detrusor botulinum toxin significantly reduced AD severity based on both frequency and severity of bladder-related events on 24-hour diaries and based on validated QoL measures. OnabotulinumtoxinA may prove a viable treatment to reduce potentially life-threatening AD due to NDO in SCI.

Acknowledgments

Grant Rick Hansen Institute, Botox donated by Allergan.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S87.

UP-08.01: The use of urodynamics in followup of neurogenic bladders treated with onabotulinumtoxinA

Michelle Bergeron ^1,², Geneviève Nadeau ^1,², Katherine Moore ^1,²

Abstract

Introduction and Objectives:

Patients with neurologic disorders may suffer from detrusor overactivity (NDO) or low bladder compliance, which can damage the upper urinary tract. Intradetrusor injections of onabotulinumtoxinA (BoNTA) have recently emerged as a treatment for NDO. Urodynamics (UDS) are currently used at initial diagnosis and at regular intervals during followup to ascertain that the intravesical pressure remains within safe limits. However, with regards to the discomfort and risks associated with UDS, our objective was to assess if UDS done at regular intervals in the followup of neurogenic bladders treated with BoNTA had an impact on management.

Methods:

We analyzed retrospectively the medical records of adult patients with neurologic disorders treated with intradetrusor injections of BoNTA for either detrusor overactivity or low bladder compliance at the Institut de réadaptation en déficience physique du Québec (IRDPQ). In our centre, UDS were routinely done at baseline and then after every fifth set of injections.

Results:

We identified 57 patients with a diagnosis of neurologic disorder. Each patient had between one and 19 sets of injections, with a mean number of 5, 61 injections, and 1–6 followup UDS representing a mean number of 2.09 UDS. Of the 119 followup UDS reviewed in our centre, urologists took the decision to interrupt treatment in five cases (4.2%), which was eventually resumed, while three patients (2.5%), due to persistence of symptoms or high intravesical pressure, had their management changed to bladder augmentation. Two regimens were suspended and one was ended due to patient’s preference.

Conclusions:

Our study showed that UDS at pre-set intervals for followup of patients receiving BoNTA injections were rarely associated with modifications in the treatment course. Therefore, UDS should only be performed in cases where there is a change in the patient’s symptoms or if the urologist suspects that the treatment response is suboptimal.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S87.

UP-08.02: A clinical perspective on collecting patient-reported outcomes at the point-of-care for urinary incontinence

Darren Desantis ¹, Richard J Baverstock ^1,², Kevin V Carlson ^1,², Andrea Civitarese ¹, Trafford Crump ¹

Abstract

Introduction and Objectives:

Treating urinary incontinence (UI) is difficult due to the quality of life impact of the patient’s symptoms, but also the side effects of treatment options themselves. Patient-reported outcomes (PROs) are a way to quantify this impact and incorporate it into clinical practice. The objective of this study is to qualitatively evaluate a novel way to collect, report, and disseminate UI PROs at the point-of-care.

Methods:

Patients visiting a multidisciplinary urology clinic for UI completed PROs on a tablet while awaiting clinical assessment. Responses were scored and linked to the patients’ previous scores. Physicians then reviewed these scores using an online “dashboard.” After applying this in clinic, qualitative interviews with physicians were recorded, transcribed, and analyzed. Guiding the interviews was a five-dimension framework: 1) applying PROs at the point-of-care; 2) logistical impact of the dashboard; 3) influence of the dashboard on clinical decisions; 4) use of the dashboard in patient conversation; and 5) user experience with the dashboard.

Results:

Six interviews were completed, from which four themes emerged. First, clinicians felt electronic PRO collection was superior to paper-based PRO collection in its ability to display results graphically, but noted that paper forms allow review of individual question responses. Second, they thought that patients would benefit from graphical displays that track progress over time, stimulating discussion between patient and clinician. Third, clinicians generally found the dashboard to be “straightforward” and “easy to use.” Fourth, several areas needed improvement, such as: inclusion of individual question responses; ability to print and export from the dashboard; output that could be more easily understood by patients; and flags for the clinician if symptoms improve or worsen.

Conclusions:

The results from this study could serve as a lesson to other clinics interested in systematically collecting PROs, with minimal impact on human resources.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S87.

UP-08.03 – WITHDRAWN

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S87–S88.

UP-08.04: Characterizing lower urinary tract symptoms in men with suspected prostate cancer

Ian TS Wright ¹, Trafford Crump ¹, Richard J Baverstock ¹

Abstract

Introduction and Objectives:

Lower urinary tract symptoms (LUTS) are known symptoms of prostate cancer. These same symptoms are also possible side effects from prostate cancer treatments. Thus, in order to evaluate post-treatment outcomes, it is critical to know pre-treatment rates. The purpose of this study is to characterize LUTS in men with suspected prostate cancer, prior to treatment.

Methods:

Data from the Alberta Prostate Cancer Research Initiative (APCaRI) clinical registry was extracted and de-identified for this study’s analysis. The APCaRI registry includes data on its participants’ pre-treatment use of medications and their self-reported symptom severity, including the Expanded Prostate Cancer Index Composite (EPIC-26) and the International Prostate Symptom Score (IPSS). The registry was searched for common medications used for benign prostate hyperplasia (BPH) and overactive bladder (OAB). Responses to the EPIC-26 were analyzed for its five domains. Responses to the IPSS were analyzed for its global score. Relevant items were extracted to characterize those men with LUTS.

Results:

A total of 661 APCaRI participants were included in the analysis, with an average age of 62 years. Of those, 38 (5%) reported using BPH-related medications and none reported using OAB-related medications. Median score for the EPIC-26’s urinary obstruction domain was 94, and 83 for the urinary incontinence domain. The median IPSS score was 6. At intake, three men had undergone transurethral resection of the prostate (TURP). The least frequent reported symptom was straining, affecting 31% of men, and the most commonly reported symptom was nocturia, affecting 87%.

Conclusions:

This study provides baseline data on LUTS in men with suspected prostate cancer. The results from this study will help future studies measure the incidence of LUTS as a result of prostate cancer treatment from a population perspective. Ongoing study will assess the effect of prostate cancer treatments on LUTS in this patient population.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S88.

UP-08.05: Treatment and management expectations of older adults with urinary incontinence

Narin Sheri ¹, William Gibson ¹, Kathleen Hunter ¹, Adrian S Wagg ¹

Abstract

Introduction and Objectives:

For many older people, urinary incontinence (UI) is a chronic disease requiring long-term therapy for symptom relief. For some, any improvement, no matter how small, may constitute a cure, while other patients discount anything less than total symptom relief. We attempted to determine expectations from treatment and what treatments older patients found acceptable to treat their UI.

Methods:

Consecutive outpatients over 65 years of age referred to a secondary-care continence clinic were assessed using a validated symptom, quality of life, and attitude questionnaire adapted from previous studies. Analysis examined relationships between quality of life, diagnosis, duration of condition, and acceptability.

Results:

121 patients (mean 77.5 years, range 65–95) participated. UI was the most bothersome symptom for the majority (42.7%), followed by urgency (21.9%), nocturia (19.8%), frequency (9.3%), and infection (6.3%). Almost half (49.6%) expected treatment to improve symptoms so that they no longer interfered with life. Short-term lifestyle modifications and procedures with no long-term risk were more popular than long-term lifestyle modifications. 85.5% identified short-term medication as the most acceptable treatment. Least popular was long-term catheterization, 6.2% acceptable, and major surgery (12.6%). Frequent nocturia, persistent stress incontinence, and frequent pad use were least desirable following treatment. There was no significant association between quality of life, acceptability of treatment types, acceptability of outcomes, or expectations of cure.

Conclusions:

Conservative treatments were more acceptable than higher-risk, possibly more effective treatments. Older people may have a pessimistic view about their value in relation to efficacy, rehabilitation, and remaining life expectancy. There were no significant associations between quality of life and expectations of treatment, acceptability of treatments, and post-treatment symptoms.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S88.

UP-08.06: Reducing the risk: Evaluating the benefit of pre-procedural ultrasound scanning in our nurse-led outpatient suprapubic catheter service

Emma Papworth ¹, Ruaraidh Macdonagh ¹, Angus MacCormick ¹

Abstract

Introduction and Objectives:

Suprapubic catheters (SPC) can provide a valuable alternative to urethral catheters in some patients, with lower associated infection rates¹^,² and no risk of urethral trauma or stricture formation.² SPCs are also less invasive for patients when performing a trial without catheter³ and are better tolerated by patients.⁴ However, risks associated with SPC insertion include bleeding, infection, recurrent urinary tract infections (UTIs), catheter blockage, and more seriously, the risk of bowel perforation.⁴ We assessed complication rates both before and after the introduction of ultrasound scanning (USS) as an adjunct to SPC insertion (using a seldinger technique) in our outpatient clinic.

Methods:

A dedicated SPC clinic was established in July 2008, undertaken by a formally structurally trained specialist nurse. In April 2013, training and experience was sufficient to enable pre-procedural USS on each patient attending for SPC insertion. Patients with overlying bowel were referred for open insertion under general anaesthetic due to significantly increased risk of bowel perforation.

Results:

322 SPCs were inserted in our clinic between July 2008 and April 2013, without the routine use of pre-procedural USS. 101 were inserted between May 2013 and June 2015 with USS guidance. After the introduction of USS, slightly more patients were referred for open insertion (without USS 7/322 (2.6%); with USS 12/101 (12%)). Following the introduction of USS, there were no recorded cases of bowel perforation associated with SPC insertion in our clinic (without USS 3/322, 0.9%; with USS 0/101, 0%).

Conclusions:

In our clinic, use of USS to identify patients with bowel overlying the bladder prior to SPC insertion has eliminated the risk of associated bowel perforation. This is accompanied by an appropriate increase in referrals for open SPC insertion. Dedicated SPC clinics provide a safe and effective service for SPC insertion and can also provide excellent opportunities for training.

References

1.Niël-Weise BS, van den Broek PJ. Urinary catheter policies for short-term bladder drainage in adults. Cochrane Database Syst Rev. 2005:CD004203. doi: 10.1002/14651858.cd004203.pub2. [DOI] [PubMed] [Google Scholar]
2.Horgan AF, Prasad B, Waldron DJ, et al. Acute retention, comparison of suprapubic and urethral catheterization. Br J Urol. 1992;70:149–151. doi: 10.1111/j.1464-410X.1992.tb15693.x. [DOI] [PubMed] [Google Scholar]
3.Ichsan J, Hunt DR. Suprapubic catheters: A comparison of suprapubic vs. urethral catheters in the treatment of acute urinary retention. Aust N Z J Surg. 1987;57:33–6. doi: 10.1111/j.1445-2197.1987.tb01236.x. [DOI] [PubMed] [Google Scholar]
4.Ahluwalia RS, Johal N, Kouriefs C, et al. The surgical risk of supra-pubic catheter insertion and long-term sequelae. Ann R Coll Surg Engl. 2006;88:210–3. doi: 10.1308/003588406X95101. [DOI] [PMC free article] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S88–S89.

UP-08.07: Comprehension and construct validity of the Visual Prostate Symptom Score by men with obstructive lower urinary tract symptoms in rural Uganda

M Lynn Stothers ¹, Andrew Macnab ¹

Abstract

Introduction and Objectives:

The Visual Prostate Symptom Score (VPSS) is a pictorial version of the International Prostate Symptoms Score (IPSS) to quantify frequency, nocturia, weak stream, and quality of life (QoL) regardless of education. Objectives: Develop VPSS construct and content validity by: 1) evaluating pictogram understanding; 2) pictogram description comparison to IPSS response; 3) obtaining patient input to enhance information capture; and 4) quantifying pictogram usefulness.

Methods:

Men presenting with lower urinary tract symptoms (LUTS) to a rural Uganda medical clinic completed the VPSS and IPSS without and with assistance; described understanding of pictograms; rated each for usefulness on a visual analogue scale, and provided feedback for imagery. Statistical analysis: Student’s t-test, Fisher’s exact, Spearman’s correlation.

Results:

N=136 scores in men mean age 69 years (45–93); school grade 8–12 (9%), grade 5–7 (9%), grade 1–4 (62%), and no schooling (20%). IPSS was completed without assistance in n=2 vs. VPSS in 94% (p≤0.05). Comparing education: With no schooling IPSS required assistance in 100% vs. 6% with VPSS (p≤0.05); grade 1–4 100% vs. 14%; and higher grades 40% vs. 0%. 94%, independent of education, had inherent recognition of the weak stream pictogram, 75% for frequency & 42% for nocturia. Likert scale measures indicated the most helpful image was “weak stream,” followed by frequency with nocturia and QoL being less clear. Subjects valued the weak stream and facial expressions after understanding that QoL related to overall LUTS impact. VPSS and IPSS QoL correlated in 60% before verbal explanation.

Conclusions:

Construct validity for immediate recognition is greatest for the slow stream pictogram. Comprehension and reporting would benefit from urgency pictograms, increased image siz, and contrast detail for nocturia, and a diagrammatic link between the QoL scale and these other constructs. VPSS development will add in the ability to measure men’s health on a global scale.

Acknowledgments

Grand Challenges Canada

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S89–S90.

UP-08.08: 180 W-LBO Greenlight XPS laser vaporization for benign prostatic hyperplasia: Evaluation of a single surgeon learning curve to attain expertise for durable and reproducible outcomes

Joris Zhou ¹, Côme Tholomier ¹, Pierre-Alain Hueber ¹, Roger Valdivieso ¹, Vincent Trudeau ¹, Vincent Misrai ², Marc Nicolas Bienz ¹, Hugo Lavigueur-Blouin ¹, Kevin C Zorn ¹

Abstract

Introduction and Objectives:

Although the learning curve to safely execute Greenlight photoselective vaporization of the prostate (PVP) for the treatment of benign prostatic hyperplasia (BPH) is considered short for a trained endourologist, the case volume needed to ensure reproducible and durable outcome regardless of prostate size has not been well-addressed. The aim of this study is evaluate intraoperative and postoperative parameters to assess our learning curve of reaching expertise.

Methods:

A retrospective study was conducted on 328 patients who underwent PVP performed by a single experienced laser surgeon with the Greenlight laser XPS-180 W for BPH. The population was divided into chronologically consecutive equal groups of patients to assess the preoperative and perioperative parameters, all collected prospectively. The drop in prostate-specific antigen (PSA) at six months and the occurrence of complications categorized according to Clavien-Dindo were also collected.

Results:

Energy delivered per prostate volume increased significantly with experience. The mean benchmark value of 4 kJ/g was attained after 165 patients. Mean PSA drop >50% at six-month was reached since the first group of patients and tended to increase with experience (Fig. 1). There were no significant differences between groups in intraoperative complications or in postoperative functional outcomes (International Prostate Symptom Score (IPSS), Qmax, post-void residual urine volume (PVR)); however, the number of Clavien-Dindo category I adverse events significantly decreased with gain of experience.

Conclusions:

The amount of energy per prostate volume increases with experience while intraoperative safety is maintained. This more confident approach translates into increased removal of prostatic tissue and decreased number of Clavien-Dindo category I with similar functional outcomes. In our experience of pioneer work with PVP, the case volume needed to achieve benchmarks related to durable clinical outcomes (PSA reduction >50%, energy usage >4 kJ/cc) was over 100 cases.

Table 5.

UP-08.08. Detailed intra-operative and early postoperative adverse events

	Group 1	Group 2	Group 3	Group 4	Group 5	Group 6	Group 7	Group 8	p value
Adverse intra-operative events

Chest pain	0 (0%)	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Transfusion	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0.541
Urethral stenosis	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
TURP conversion	1 (2.4%)	1 (2.4%)	0 (0%)	1 (2.4%)	1 (2.4%)	2 (4.9%)	3 (7.3%)	0 (0%)	0.512
Capsular perforation	0 (0%)	0 (0%)	1 (2.4%)	1 (2.4%)	0 (0%)	0 (0%)	1 (2.4%)	1 (2.4%)	0.779
False passage	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Total intra-operative	2 (4.9%)	2 (4.9%)	1 (2.4%)	3 (7.3%)	1 (2.4%)	2 (4.9%)	3 (7.3%)	1 (2.4%)	0.912

Adverse postoperative events (<30 days)

Clavien-Dindo category 1

Incontinence	3 (7.3%)	3 (7.3%)	2 (4.9%)	0 (0%)	0 (0%)	0 (0%)	2 (4.9%)	0 (0%)	0.133
Hematuria	8 (19.5%)	10 (24.4%)	3 (7.3%)	0 (0%)	0 (0%)	2 (4.9%)	1 (2.4%)	0 (0%)	<0.001
LUTS	7 (17.1%)	14 (34.1%)	7 (17.1%)	3 (7.3%)	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	<0.001
Constipation	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Vomiting	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Diminution of overall state of health	0 (0%)	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Total for category I	16 (39.0%)	21 (51.2%)	12 (29.3%)	4 (9.8%)	0 (0%)	2 (4.9%)	4 (9.8%)	0 (0%)	<0.001

Clavien-Dindo category II

Urosepsis	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0.541
Erectile dysfunction	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Incontinence	3 (7.3%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.003
Hematuria	2 (4.9%)	0 (0%)	4 (9.8%)	2 (4.9%)	2 (4.9%)	2 (4.9%)	3 (7.3%)	0 (0%)	0.413
LUTS	1 (2.4%)	2 (4.9%)	1 (2.4%)	1 (2.4%)	0 (0%)	0 (0%)	2 (4.9%)	1 (2.4%)	0.773
Retention	5 (12.2%)	3 (7.3%)	4 (9.8%)	4 (9.8%)	4 (9.8%)	3 (7.3%)	2 (4.9%)	0 (0%)	0.563
Urinary tract infection	3 (7.3%)	1 (2.4%)	0 (0%)	1 (2.4%)	0 (0%)	2 (4.9%)	3 (7.3%)	2 (4.9%)	0.442
Fever	2 (4.9%)	1 (2.4%)	1 (2.4%)	1 (2.4%)	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0.696
Paraphymosis	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (2.4%)	0.431
Atrial fibrillation	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Prostatitis	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0.431
Osteitits pubis	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0.431
Gout	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Total for category II	11 (26.8%)	7 (17.1%)	12 (29.3%)	7 (17.1%)	7 (17.1%)	6 (14.6%)	10 (24.4%)	4 (9.8%)	0.329

Clavien-Dindo category IIIb

Hematuria	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	1 (2.4%)	0 (0%)	0.541
Post-fall fracture	0 (0%)	0 (0%)	0 (0%)	2 (4.9%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.048^*
BNC	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
False passage	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0.431
Total for category IIIb	0 (0%)	0 (0%)	1 (2.4%)	2 (4.9%)	2 (4.9%)	0 (0%)	1 (2.4%)	0 (0%)	0.386

Clavien-Dindo category IVa

Acute renal failure	0 (0%)	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Myocardial infarction	0 (0%)	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Total for category IVa	0 (0%)	0 (0%)	1 (2.4%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.541

Clavien-Dindo category V

Death from heart failure	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431
Total for category V	0 (0%)	1 (2.4%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0.431

Return to hospital

Emergency room visit	4 (9.8%)	2 (4.9%)	3 (7.3%)	4 (9.8%)	4 (9.8%)	3 (7.3%)	5 (12.2%)	2 (4.9%)	0.926
Re-admission	4 (9.8%)	0 (0%)	3 (7.3%)	2 (4.9%)	1 (2.4%)	2 (4.9%)	1 (2.4%)	1 (2.4%)	0.448

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BNC: bladder neck contracture; LUTS: lower urinary tract symptoms; TURP: trans-urethral resection of the prostate

^*

On post-hoc analysis, no significant differences between the groups.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S89, S91.

UP-08.09: Development of a patient-centred impact inventory to deliver value to interstitial cystitis/bladder pain syndrome patients

Nicole Golda ¹, J Curtis Nickel ², Sender Herschorn ¹, Lesley K Carr ¹

Abstract

Introduction and Objectives:

Disease-specific instruments were designed to assess symptoms in interstitial cystitis/bladder pain syndrome (IC/BPS) for inclusion and outcomes in clinical trials. We developed the IC/BPS Impact Inventory, a pilot patient directed, value-based instrument to fulfill an unmet need for a questionnaire that could reliably assesses an IC/BPS patient’s disease course and efficacy of treatment in clinical practice.

Methods:

In-depth interviews with healthcare team members (HCT) and patients, focus groups, and individual surveys were conducted in Kingston and Toronto to record and rank their treatment goals and values, which were pooled and analyzed for emergent domains and priority rankings. Purposive sampling methodology was used and sample size was determined once a consensus was reached by the focus group and individual surveys to create an initial draft of questions used for formal cognitive testing.

Results:

39 HCT members across Canada completed a non-validated survey, producing a ranked list of the most important values associated with providing care in IC/BPS. Multidisciplinary support, education, and diagnostic and treatment algorithms were highly valued. Current diagnostic and followup questionnaires were not valued as effective or useful in clinical practice. Patient focus groups were conducted at two universities (n=15 patients). All agreed that there was a lack of physician awareness, leading to frustration and delay in diagnosis. There was consensus that current questionnaires lacked emphasis on evaluating anxiety/stress level, quality of life impact, and ability to cope with disease flares. After an iterative process of obtaining feedback from patients and expert review, 23 questions were selected for the IC/BPS Impact Inventory.

Conclusions:

The IC/BPS Impact Inventory is a patient-focused questionnaire currently undergoing formal validation testing. This instrument will assesses what patients value in their disease course and assist urologists in evaluating level of disease impact and efficacy of current treatment.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S91.

UP-08.10: Multicentre, international experience of 180 W LBO laser photovaporization in men with large prostates (prostate volume >100cc): Long-term outcomes of 434 patients

Pierre-Alain Hueber ¹, Malek Meskawi ¹, Roger Valdivieso ¹, Franck Bruyere ², Vincent Misrai ³, Georges Fournier ⁴, Ravi Munver ⁵, Ganesh Siravajan ⁵, Alexis Te ⁶, Bilal Chughtai ⁶, Matthew Rutman ⁷, Dean S Elterman ⁸, Martel Tristan ¹, Mounsif Azizi ¹, Kevin C Zorn ¹

Abstract

Introduction and Objectives:

Prostate volume (PV) >100 cc remains challenging for endoscopic benign prostatic hyperplasia (BPH) management. Although photoselective vaporization of the prostate (PVP) using XPS-180 system is feasible for patients with large PV, long-term outcome data supporting its use is still lacking.¹ The aim was to evaluate the outcomes and durability at four years in a large, multicentre experience.

Methods:

This is a retrospective study of 434 men with preoperative transrectal ultrasound (TRUS) PV >100 cc that were treated in eight centres in North America (Canada, U.S.) and Europe (France) with the Greenlight-XPS laser using PVP for the treatment lower urinary tract symptoms (LUTS) associated with BPH. To assess efficacy, International Prostate Symptom Score (IPSS), Qmax, prostate volume (PV), post-void residual (PVR), and prostate-specific antigen (PSA) were measured at six, 12, 36, and 48 months. Durability was evaluated using retreatment rate at 24, 36, and 48 months.

Results:

Median prostate size and PSA were 121 cc (interquartile range (IQR) 108–150) and 6.3 ng/mL. 42.3% of men had an indwelling catheter at the time of surgery. Median operative time and energy applied were 60 minutes (IQR 40–74) and 424 kJ, with ≥2 fibers used in 40% of the cases. Median energy delivery was 3.4 kJ/cc per case. Median length of stay was 24 hours. IPSS, Qmax, and PVR were significantly improved at all endpoints, including at 48 months (Fig. 1). Surgical BPH retreatment was 5.3% at 24 months, which rose to 11.9% at 36 months. Interestingly, characteristics of retreated men include energy delivery that was 2.4 kJ (vs. 3.4kJ) and PSA reduction at 12 months of 29% (vs. 46%) (Table 1).

Conclusions:

PVP treatment using Greenlight XPS-180 W can potentially provide durable improvements with regards to functional outcomes including IPSS at four years. However, retreatment rate rising after three years is a concern. This data highlights the need of using a standardized technique with an operative endpoint of an enucleation-like-defect (down to the surgical capsule). 12-month PSA reduction and rising PSA during followup may serve as surrogate markers for predicting durability.

Table 1.

UP-08.10.

Retreatment at 36 months Patient characteristics	Retreated (n=17)	Non-retreated (n=143)	p value
Median age	73	71.5	0.8
Median preoperative PVR	275	120	0.02
Median preoperative TRUS	150	120	0.05
Median preoperative PSA	7.4	6	0.05
Energy delivered (kJ/cc)	2.4	3.4	0.3
Decrease PSA 6 months	34.3%	46.0%	0.3
Decrease PSA 12 months	29.0%	42.0%	0.02
Decrease PSA 24 months	21.0%	48.0%	0.01

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References

1.Hueber PA, Bienz MN, Valdivieso R, et al. Photoselective vaporization of the prostate for benign prostatic hyperplasia using the 180 Watt system: Multicentre study of the impact of prostate size on safety and outcomes. J Urol. 2015;194:462–9. doi: 10.1016/j.juro.2015.03.113. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S92.

UP-08.11: The predictive value of dipstick urine analysis and urine flow cytometry for detecting bacteriuria prior to Greenlight laser vaporization of the prostate

Helge Seifert ¹, Malte Rieken ¹, Armin Halla ¹, Oliver Braissant ¹, Adrian Egli ², Axel Regeniter ³, Thomas C Gasser ¹, Alexander Bachmann ¹, Gernot Bonkat ¹

Abstract

Introduction and Objectives:

Urine cultures (UC) are recommended prior to transurethral prostate surgery, such as Greenlight laser vaporization of the prostate (GLV), to rule out bacteriuria. However, UC has a typical time delay of 24–48 hours between sample acquisition, pathogen identification, and delivery of antimicrobial susceptibility testing results. The aim of our study was to determine the diagnostic accuracy of dipstick testing and urine flow cytometry to predict bacteriuria in patients undergoing GLV of the prostate.

Methods:

Retrospective analysis of 567 urine samples from 458 patients who underwent GLV with the 180-W XPS laser for benign prostatic obstruction between April 2010 and August 2015. In patients with an indwelling transurethral catheter, urine specimens were obtained after catheter removal via a freshly placed catheter. Specimens were sent for conventional UC, urine flow cytometry (UFC), and automated dipstick analysis (DA). Sensitivity and specificity of UFC and DA in predicting bacteriuria were compared to UC.

Results:

Overall, UC culture, UFC, and DA were positive in 22%, 52%, and 53% of the cases, respectively. Samples obtained via midstream urine culture (MSSU) were positive in 12%, 28%, and 33%, respectively, compared to 35%, 84%, and 81% of specimens obtained from patients with indwelling catheter. In MSSU cases, the sensitivity and specificity of UFC (86% and 80%) were significantly (p<0.05) higher compared to DA (84% and 74%). In specimens obtained from patients with indwelling catheter, the sensitivity and specificity of UFC (98% and 24%) and automated DA (95% and 27%) were comparable and showed no statistically significant difference.

Conclusions:

Urine flow cytometry may be recommended to rule out bacteriuria in patients prior to GLV without indwelling catheter. Due to high sensitivity and high specificity, obtaining a urine culture may be regarded as unnecessary in patients with negative urine samples. In patients with indwelling transurethral catheters, urologists should ensure that the results of urine cultures are available prior to GLV.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S93.

MP-09.01: Comparison of the new ShockPulse intracoroporeal lithotripter to three commercially available ultrasonic lithotripters

Andre A Matteliano ¹, Ben H Chew ², Ryan F Paterson ², Thomas J De los Reyes ², Dirk Lange ²

Abstract

Introduction and Objectives:

Ultrasonic intracorporeal lithotripters are used during percutaneous nephrolithotomy for stone fragmentation and removal. We performed standardized bench testing of the new ShockPulse^TM stone eliminator against three commercially available systems to determine differences and nuances in performance against both hard and soft stones.

Methods:

The new ShockPulse (Olympus) intracorporeal lithotripter was tested against the LUS-2^TM (Olympus), Cyberwand^TM (ACMI/Olympus) and EMS LithoClast^TMin a standardized setting using hard (Utracal 30: U30) or soft (plaster of Paris: POP) stones. Using a rigid nephroscope, irrigation, camera, and video screen, the time to fragment equally sized U30 and POP stones in a rubber kidney model was assessed by three surgeons. The time needed to fragment each stone into pluckable fragments was first recorded, followed by the time to fully eliminate all fragments with the lithotripter. To determine the efficacy of each system at various pressures, a hands-free apparatus was used to transmit 1, 1.5, and 2 lbs of fixed force to both solid cylindrical stones and groups of six smaller stone fragments. The time required to fragment the stones was recorded at each fixed force.

Results:

The time to create pluckable fragments in the kidney model was similar among all four lithotripters for both POP stones (17–23 seconds) and U30 stones (25–33 seconds). The time to total fragmentation of free stones was similar for three of the lithotripters (45–66 seconds), which were all significantly faster than the Cyberwand system (112 seconds, p=0.046) for both U30 and POP stones (p=0.001). When fixed force testing was applied to solid cylindrical stones, the ShockPulse and Cyberwand were significantly faster at all fixed forces (p<0.0001). The LUS-2 was unable to fragment stones at 1 or 2 lbs of fixed force, and was only able to penetrate at 1.5 lbs of force. When fixed force testing was applied to the six smaller fragments, the ShockPulse was significantly faster than the other models at 1 lb (p<0.001) and 1.5 lbs (p<0.002). At 2 lbs, the Cyberwand was the slowest (p<0.0001), with no observed difference between the other three lithotripters (p=0.09).

Conclusions:

The ShockPulse lithotripter is equally as effective as current commercially available lithotripters. It was significantly faster at fragmenting stones at lighter fixed forces, which are more in keeping with those pressures applied clinically. The ShockPulse also performed equally well at greater fixed forces.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S93.

MP-09.02: Outcomes of establishing the acute stone clinic: A single centre review

Mark Assmus ¹, Shubha K De ², Derek Bochinski ², Trevor D Schuler ², Timothy A Wollin ²

Abstract

Introduction and Objectives:

Patients with symptomatic urolithiasis often present to emergency departments (ED) or family physicians preceding referral to urologists. Given significant pain, time of lost work, and potential renal function decline, prompt transition to definitive management is crucial. In 2014, the University of Alberta, Division of Urology established an acute stone clinic (ASC), with the goal of improving access to specialist care for adults with symptomatic upper tract stones. Our hypothesis is that average time to urological consultation and definitive management is shorter following ASC implementation.

Methods:

We retrospectively reviewed 337 adult patients referred to urology for stone management at our institution. Three distinct cohorts were studied. Group 1 includes patients seen during two consecutive months (Feb–March 2009) prior to inception of a general urology emergency clinic (pre-EC). Group 2 were seen Feb–March 2012 after creating the EC and Group 3 was seen after establishing the ASC (Feb–March 2015). We examined time to consultation, management, and outcomes.

Results:

337 patients (75-pre-EC, 91-EC, 171-ASC) with mean age of 48 years (range 18–93) were reviewed. Referrals came from the ED in 67% (227/337), primary care physicians in 26% (88/337), urologists in 6% (20/337), and other in 1% (2/337) of cases. The median time to urology consultation for pre-EC, EC, and ASC cohorts was 20, seven and six days, respectively (p<0.05 between pre-EC and EC or ASC). On average, the number of patients seen per week in the pre-EC, EC, and ASC groups was nine, 11, and 20, respectively. The median time to resolution of the referred calculi from date of referral for the pre-EC, EC, and ASC cohorts was 42, 32, and 18 days, respectively (p<0.05 between all cohorts).

Conclusions:

These outcomes reveal our improved institutional triaging system, with more patients seen in conjunction with shorter time to consultation and treatment.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S93–S94.

MP-09.03: Urinary sodium and hypercalciuria in metabolic stone clinic patients

Marie S Dion ¹, Daniel Olvera-Posada ¹, Husain K Alenezi ¹, John D Denstedt ¹, Hassan Razvi ¹

Abstract

Introduction and Objectives:

Moderate dietary sodium restriction has been demonstrated in clinical trials to reduce the risk of nephrolithiasis. Urinary sodium as measured by 24-hour urine analysis correlates with daily sodium intake. High sodium intake is associated with hypercalciuria and hypoci-traturia. The purpose of our study was to determine the impact of elevated urinary sodium levels on hypercalciuria in patients at metabolic stone clinic.

Methods:

A prospectively collected database of metabolic stone clinic patients from September 2001 to October 2015 was reviewed. Patients were excluded if they had incomplete 24-hour urine collections based on urinary creatinine levels or missing data. The proportion of patients with elevated urinary sodium was determined. In patients with a second 24-hour urine collection we assessed the proportion of patients with resolution of hypercalciuria based on normalized urinary sodium levels. A multivariate logistic regression was completed to assess variables that significantly impacted hypercalciuria.

Results:

In 914 patients with initial 24-hour urine analyses, 189 (20.7%) had elevated urinary sodium levels. Of these patients, 81 (42.9%) also demonstrated hypercalciuria that was twice as high as the rate of hypercalciuria in the overall population (21.9%). On a second 24-hour urine analysis, 60 patients were able to achieve normal urinary sodium levels and in these patients, hypercalciuria resolved 85.0% of the time. On multivariate logistic regression of 1229 24-hour urine samples, elevated urinary sodium resulted in a statistically significant increase in hypercalciuria with an odds ratio of 2.54 (95% CI 1.74–3.70; p<0.001).

Conclusions:

Elevated urinary sodium is a common finding at metabolic stone clinic and can have a significant impact on hypercalciuria and subsequent recurrence of stone disease. Patients should be counselled regarding the importance of dietary salt restriction and a high rate of resolution of hypercalciuria anticipated in those patients able to decrease salt intake.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S94.

MP-09.04: Natural history, complications, and re-intervention rates of asymptomatic residual stone fragments post-ureteroscopy: A report from the EDGE Research Consortium

Ben H Chew ¹, Hilary Brotherhood ¹, Roger L Sur ², Bodo E Knudsen ³, Nicole L Miller ⁴, Courtney Yong ³, Tracy Marien ⁴, An-Qi Wang ², Cameron Charchenko ⁵, Amy E Krambeck ⁵, Mitchell R Humphreys ⁶

Abstract

Introduction and Objectives:

Non-obstructing fragments <4 mm are termed “clinically insignificant residual fragments” (CIRFs) — a controversial term due to high rates of re-intervention. We examined the natural history, complication, and re-intervention rates of fragments following ureteroscopy.

Methods:

Data was collected retrospectively from members of the Endourology Disease Group for Excellence (EDGE) in 232 patients with residual fragments following ureteroscopy (URS) from 2006–2013. Patients with at least one KUB X-ray, ultrasound (US), or computed tomography (CT) within 12 months were studied for fragment location, size, growth, passage, complication, and re-intervention rates.

Results:

Of the 232 subjects, 131 (56%) required no further intervention and remained asymptomatic, 34 (15%) developed complications requiring no intervention, and 67 (29%) required intervention. Fragments >4 mm were more likely to grow over time (p<0.001) and have complications (p=0.039). Logistic regression shows the original stone size (p=0.0475) to be the only significant predictor of complication. Re-intervention was predictable based on the size (p=0.017) and location of fragments (p=0.02). There was a trend towards complication depending on the location of residual fragments (p=0.068) and re-intervention with older age (p=0.075). Kaplan-Meier analysis found that dusting the stone and larger residual fragments (>4 mm) were more likely to require re-intervention (p=0.004). Re-interventions included URS (58), percutaneous nephrolithotomy (PCNL) (4), and shock wave lithotripsy (SWL) (3).

Conclusions:

This study suggests that fragment sizes >4 mm following ureteroscopy is associated with significantly higher rates of stone growth, complications, and need for re-intervention. Even for fragments <4 mm, 28% underwent stone growth and 22% suffered a complication, challenging the traditional description of CIRF. Ensuring complete stone-free status is the best way to reduce the rate of complications and interventions following ureteroscopy.

Table 1.

MP-09.04. Summary of results

	Fragment <4 mm	Fragment ≥4 mm	p value
Passage of fragments	27.3%	26.0%	0.948
Growth of fragments	27.8%	59.2%	<0.001^***
Complication	22.3%	35.7%	0.039^*
Re-intervention req’d	17.5%	38%	0.001^*

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S94.

MP-09.05: Routine preoperative electrocardiograms in patients at low risk for cardiac complications during shockwave lithotripsy: Are they useful?

Robert J Sowerby ¹, Daniela Ghiculete ¹, Aaron Hong ², Monica A Farcas ¹, Keith P Barrett ¹, Jason Y Lee ¹, Michael Ordon ¹, Kenneth T Pace ¹, R John D Honey ¹

Abstract

Introduction and Objectives:

Routine preoperative electrocardiogram (ECG) prior to shockwave lithotripsy (SWL) is frequently performed, despite recommendations against its use in asymptomatic patients undergoing low-risk surgical procedures.¹ This study aims to determine if routine preoperative ECG prior to SWL is useful in patients at low risk for cardiac complications.

Methods:

A retrospective study of 30 892 patients referred for SWL (2003–2013) reviewed all cardiac-related preoperative cancellations, intraoperative complications, postoperative admissions, and emergency department (ED) presentations. Patients received SWL with sedation and continuous 5-lead ECG monitoring. Patients with <1% risk of major cardiac event (Revised Cardiac Risk Index) and no history of arrhythmia were classified as low risk for cardiac complications.²

Results:

Preoperative ECG triggered 13 (0.04%) cancelations in low-risk patients (one atrial fibrillation, 12 ischemia/previous infarction). Of these 12 patients, only one had subsequent abnormal cardiac workup and 10 patients underwent uncomplicated SWL without cardiac intervention (two history unknown). Of 27 722 SWL treatments, five (0.02%) were stopped prematurely in low-risk patients due to arrhythmia in which preoperative ECG was normal (three), abnormal (one), and not completed (one). Three patients developed arrhythmia with sedation and two patients were admitted postop due to cardiac complications (one atrial fibrillation, one hypertension), of whom all had normal preoperative ECG. No patients presented to our ED with cardiac complications after SWL.

Conclusions:

In patients at low risk for cardiac complications, preoperative ECG triggered few cancellations and did not predict arrhythmia during sedation, early termination of treatment, or cardiac complications after SWL. These findings suggest that in low-risk patients, routine preoperative ECG has little effect on treatment or complication rate and should be omitted, representing a significant cost savings.

References

1.Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing non-cardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e278–333. doi: 10.1161/CIR.0000000000000106. [DOI] [PubMed] [Google Scholar]
2.Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major non-cardiac surgery. Circulation. 1999;100:1043–9. doi: 10.1161/01.CIR.100.10.1043. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S94–S95.

MP-09.06: Determining optimal laser settings for non-contact laser lithotripsy (“popcorning”)

Keith P Barrett ¹, Jason Y Lee ¹, R John D Honey ¹

Abstract

Introduction and Objectives:

Intra-renal laser lithotripsy often produces fragments that may result in future episodes of colic or obstruction. Basket extraction of these fragments may be time-consuming and inefficient. While non-contact laser lithotripsy (“popcorning”) is commonly used to further reduce such fragments, optimal settings for this approach remain unclear. The objective of this study was to use and in-vitro model to determine the optimal laser settings for “popcorning.”

Methods:

A 12 mm diameter test tube filled with 0.9% normal saline was used to simulate a calyx, and a 365 µ holmium laser fiber was positioned 2 mm above 2 × 4 mm soda-lime phantoms. Two different laser settings were used: 1.0 J/10 Hz (high-energy/low-rate; H/L) and 1.0J/40 Hz (high-energy/high-rate; H/H). Wet weight of the phantoms was recorded prior to lithotripsy. Lithotripsy was carried out for durations of 30 and 90 seconds, with residual weight recorded after each run. In addition, the residual stone was run through a 2 mm sieve, and the weight of fragments >2 mm was recorded. Three runs were performed for each duration at each setting.

Results:

Baseline wet weight of the samples were comparable between the groups (0.176 g vs. 0.171 g; p=0.272). After 30 seconds of lasering, the reduction in residual weight was 0.021 g (−11.8%) in the H/L group and 0.035g (−20.6%) in the H/H group (p=0.154). The residual % of weight >2 mm was 88.2% in the H/L group and 66.7% in the H/H group (p=0.019). After 90 seconds of lasering, the reduction in residual weight was 0.052 g (−13.6%) in the H/L group and 0.051g (−29.3%) in the H/H group (p=0.009). The residual % of weight >2 mm was 68.2% in the H/L group and 43.2% in the H/H group (p=0.033).

Conclusions:

The high-energy/high-rate setting resulted in significantly greater vaporization at 90 seconds and significantly greater fragmentation at 30 and 90 seconds. Use of higher rates appears to be associated with greater efficiency of non-contact laser lithotripsy.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S95.

MP-09.07: A multicentred regional emergency department study of renal colic management using medical expulsion therapy

Erin Bristow ¹, Adam Kinnaird ², Trevor D Schuler ², Pamela Pang ¹, Stephanie Couperthwaite ¹, Cristina Villa-Roel ¹, Brian H Rowe ¹

Abstract

Introduction and Objectives:

Patients with renal colic present frequently to the emergency department (ED). Existing literature suggests management with medical expulsion therapy (MET) may improve outcomes, especially for those with stones >5 mm in size. This study evaluates the use of MET in the management of adult patients seen in regional EDs with a diagnosis of renal colic.

Methods:

A multicentred medical chart review study was conducted in seven Edmonton-Zone EDs. Approximately 100 cases from each site were randomly selected from administrative data from the 2014 calendar year; no repeat cases were permitted. Using a standardized data collection process and trained research assistance, data were abstracted from medical charts. Medians and interquartile ranges (IQR), proportions, and odds ratios (OR) with 95% confidence intervals (CIs) are reported.

Results:

Overall, 656 patient charts were included in the review; median age was 46 years (IQR 35, 46) and 248 (38%) were female. Many (198 (30%)) received no initial ED imaging; computed tomography (CT) (223 (34%)) was favoured over ultrasound (34 (6%)) for initial imaging. Only 198 (31%) of charts contained documentation of the use of MET at discharge and the median duration of therapy was 10 days (IQR 7, 14). Intitiation of MET therapy did not vary based on older age (OR 1.29; 95% CI 0.91, 1.81); sex (OR 1.03; 95% CI 0.73, 1.45); resident involvement (OR 1.01; 95% CI 0.57, 1.82); or presentation to an academic centre (OR 0.80; 95% CI 0.56, 1.14); however, MET was used more for larger (>5 mm) stone size (OR 1.6; 95% CI 1.0, 2.64).

Conclusions:

Management of renal colic with MET is uncommon in this region and practice variation appears driven by physician preference rather than evidence. Practice guidelines with standardized order sets are urgently needed to improve care.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S95–S96.

MP-09.08: The impact of body mass index on adverse outcomes in percutaneous nephrolithotomy

Mounsif Azizi ¹, Jessica Paonessa ², James E Lingeman ², Naeem Bhojani ^1,²

Abstract

Introduction and Objectives:

Obesity among patients in North America is increasing and so is stone disease. Percutaneous nephrolithotomy (PCNL) remains the standard of care for renal calculi ≥2 cm. Whether body mass index (BMI) has an impact on adverse outcomes in renal percutaneous surgery is still not well-defined. This study sought to compare outcomes of PCNL in patients of various BMI.

Methods:

A retrospective chart review was performed to include all procedures done at our institution between 2007 and 2011. Patients were categorized into four groups based on their BMI using the World Health Organization classification for obesity: normal weight (18.5–24.9 kg/m2), obesity class I (30.0–34.9), obesity class II (35.0–39.9) and obesity class III (≥40). Preoperative, operative, and postoperative outcomes were compared. Complications were reported according to the Clavien-Dindo grading system. All procedures were performed in the prone position by a single surgeon.

Results:

391 patients were included in this study: 78 (19.4%) with normal weight and 207 (51.4%) with a BMI ≥30. Patients with obesity (class I–III) had a statistically significant higher baseline serum creatinine (p=0.02) and more hypertension, diabetes, and gout (all p<0.001) compared to patients with ideal body weight. Operating time and length of hospital stay were similar between groups. Postoperatively, patients with a BMI ≥30 had a greater serum creatinine (p<0.001) and hemoglobin (p=0.02) at 24 hours compared to patients with normal weight. There was no statistically significant difference in terms of blood transfusions or Clavien-Dindo complications between groups.

Conclusions:

Over half of the patients in our cohort had a BMI ≥30. This study demonstrated that adverse outcomes of PCNL were statistically independent of BMI. Therefore, obesity should not be considered a contraindication to PCNL.

Table 1.

MP-09.08. Distribution of patients by body mass index

	BMI	N (%)
Underweight	<18.5	11 (2.7%)
Normal weight	18.5–24.9	78 (19.4%)
Overweight	25–29.9	106 (26.4%)
Class I obesity	30–34.9	81 (20.1%)
Class II obesity	35–39.9	48 (11.9%)
Class III obesity	≥40	78 (19.4%)

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Table 2.

MP-09.08. Preoperative, operative, and postoperative characteristics

	Normal weight (18.5–24.9)	Class I obesity (30.0–34.9)	Class II obesity (35.0–39.9)	Class III obesity (≥40)	p value^*
Preoperative characteristics
N (%)	78 (19.4%)	81 (20.1%)	48 (11.9%)	78 (19.4%)
Mean age (years)	52.2	54.8	55.1	54.3	0.2
Gender, n (%)
Male	25 (32%)	40 (49%)	24 (50%)	32 (41%)	0.03
Female	53 (68%)	41 (51%)	24 (50%)	46 (59%)
HTN, n (%)	19 (24.4%)	38 (46.9%)	34 (70.8%)	50 (64.1%)	<0.001
Diabetes, n (%)	7 (9.0%)	24 (29.6%)	16 (33.3%)	37 (47.4%)	<0.001
Gout, n (%)	0 (0%)	3 (3.7%)	3 (6.2%)	8 (10.2%)	<0.001
Operative characteristics
Bilateral PCNL, n (%)	17 (22.0%)	18 (22.2%)	11 (22.9%)	20 (25.6%)	0.7
Preoperative hemoglobin (g/dl)	13.6 (8.7–17.6)	14.0 (8.7–18.3)	13.7 (8.9–16.8)	13.3 (10.1–17.8)	1.0
Postoperative hemoglobin (g/dl)	11.1 (5.4–14.2)	11.7 (6.8–15.8)	11.6 (7.6–15.0)	11.5 (8.2–16.3)	0.02
Preoperative creatinine (mg/dl)	1.0 (0.5–2.4)	1.1 (0.4–2.8)	1.1 (0.4–2.6)	1.1 (0.6–3.6)	0.02
Postoperative creatinine (mg/dl)	1.1 (0.5–2.1)	1.3 (0.7–3.1)	1.3 (0.6–3.5)	1.4 (0.6–3.9)	<0.001
Operating room time (minutes)	128.2 (40–272)	124.8 (40–300)	122.1 (43–306)	130.7 (30–266)	0.8
Postoperative characteristics
Length of stay (days)	2.4 (1–10)	2.4 (1–12)	2.2 (1–13)	2.7 (1–21)	0.9
Clavien-Dindo complications, n (%) Grades I–IVa	10 (12.8%)	11 (13.6%)	6 (12.5%)	14 (17.9%)	0.6
Blood transfusions, n (%)	5 (6.4%)	0 (0%)	2 (4.5%)	4 (5.1%)	0.2

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^*

Values obtained by Chi square test.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S96.

MP-09.09: Secondary diagnostic imaging findings significance in ureteric colic

Dean Wong ¹, Grant Innes ², Taylor E Remondini ¹, Navraj Dhaliwal ¹, Ravneet Dhaliwal ¹, Adrian Frusescu ¹, Bryce A Weber ¹

Abstract

Introduction and Objectives:

Computed tomography (CT) is commonly used to diagnose and characterize stones in the urinary tract. Stone size and location are strong predictors used to determine types of intervention used in the acute setting. However, the prognostic significance of hydronephrosis or peri-ureteral/peri-nephric stranding at the index visit is unclear. We aim to determine if the presence of hydronephrosis or stranding are associated with revisits to the emergency department (ED), admissions or surgical interventions in 60 days in both the medical therapy group and the surgical intervention group.

Methods:

Imaging data was collected from ureteric colic patients from multiple centres in Calgary, Alberta. CT scans were used to confirm the presence of ureteral stones, hydronephrosis, and stranding. Imaging data was linked with hospital data regarding ED revisits, admissions, and interventions.

Results:

1850 patients from four hospitals had imaging confirmed ureteric stones. A CT scan was used to confirm the presence of a stone for 1732 (93.6%) of these patients. Stranding was noted for 60.2% of CT patients in their imaging reports. Of the patients who had surgical intervention, 62.4% had stranding, while 58.1% of medically managed patients had stranding (p=0.078). There was no significant difference between patients who either had or did not have stranding in terms of revisiting the ED (p=0.21), admissions (p=0.80), and having to undergo a procedure within 60 days of the index visit (p=0.66). Hydronephrosis was seen on 85.3% of the CT imaging reports. 92.5% of surgical patients had hydronephrosis, while 80.3% of medically managed patients had hydronephrosis (p<0.001). Patients with hydronephrosis on their CT scan, however, were more likely to have a procedure performed (p=0.022). No difference was seen for revisits to the ED (p=0.98). No further significant difference for hydronephrosis cases was seen when examining surgically and medically managed patients separately.

Conclusions:

For patients with acute renal colic, the secondary feature of stranding on CT scan is not associated with increases in ED revisits, future admissions, or procedures following their index visit. The presence of hydronephrosis on CT scan, however, results in an increased likelihood of procedures being performed after the index visit. These findings are important to consider when counselling patients with symptomatic ureteric stones.

Acknowledgments

MSI Foundation, Edmonton, AB

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S96–S97.

MP-09.10: Understanding the predictors of negative ureteroscopy: Can we reduce the risk of unnecessary surgery?

Callum Lavoie ¹, Max Levine ¹, Shubha K De ¹, Trevor D Schuler ¹, Timothy A Wollin ¹, Derek Bochinski ¹

Abstract

Introduction and Objectives:

Negative ureteroscopy (nURS) describes when no stone is found in the kidney or ureter, despite imaging suggesting the presence of a stone. The objective of this study was to identify the prevalence of and factors predictive of nURS.

Methods:

We performed a retrospective review of 245 URS procedures for kidney stone treatment performed by three endourologists between January 1 and June 30, 2014. Variables assessed included: demographics, previous stone treatment, stented prior to URS, stone-specific characteristics, time from imaging to procedure, type of intervention, etc. Statistical analysis consisted of descriptive statistics, as well as univariate and multivariate logistic regression analyses using SPSS software version 23.0.

Results:

The overall rate of negative URS was 8.98%, and the average patient was 53 years old, average body mass index (BMI) 30.3, and 52.7% were male. Smaller stones were more likely to result in nURS (OR 0.73; 0.60–0.90; p=0.003), with the average stone size being 6.3 ± 3.5 mm for nURS (vs. 9.3 ± 4.5 mm +URS). The use of a semi-rigid ureteroscope (57.1% of procedures) was associated with greater likelihood of nURS (OR 5.64; 1.62–19.65; p=0.007). Only stone size remained a significant predictor in multivariate analysis (OR 0.76; 0.62–0.94; p=0.011). More nURS stones were <4 mm (27.3% vs. 5.8%), while fewer were >10 mm (9.1% vs. 38.5%). Distal ureteral stones comprised 45.5% of nURS cases, with an average stone size of 6.5 mm, compared to 29.8% of +URS cases, with an average stone size of 7.7 mm.

Conclusions:

The rate of nURS was relatively low in our patient population, but not clinically insignificant. Intuitively, it appears as though smaller, distal stones are more likely to pass by the time patients make it to the operating room, suggesting updated preoperative imaging should help play a role in preventing unnecessary instrumentation of these patients. The use of semi-rigid URS being a predictor of passed stones is likely related to an ureterovesical junction (UVJ) position of the distal stone on prior imaging.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S97.

MP-09.11: Ambient temperature and the risk for renal colic: A population-based study of the impact of demographics and comorbidity

Michael Ordon ^1,², Blayne K Welk ^2,³, Qiongsi Li ⁴, Jun Wang ⁴, Eric Lavigne ^5,⁶, Abderrahmane Yagouti ⁷, Ray Copes ^4,⁸, Richard T Burnett ⁹, Sabit Cakmak ⁹, Hong Chen ^3,^4,⁸

Abstract

Introduction and Objectives:

To examine the impact of ambient temperature on the incidence of emergency department (ED) admissions for acute renal colic (RC).

Methods:

We conducted a population-based, time-series analysis using linked healthcare databases in Ontario, Canada. The study population consisted of all residents of Ontario, age ≥19 years, who were admitted to the ED from April 2002 to December 2013. The primary outcome was daily number of RC admissions to the ED from each of Ontario’s 14 health regions. A distributed lag non-linear model with 21 days of lag was applied to estimate the cumulative effect of temperature on RC ED visits, controlling for humidity, holidays, long-term trends, and day of the week. We estimated risks for cold and heat, defined as temperatures below and above the optimal temperature, which corresponded to the point with minimum risk of RC admissions. We conducted stratified analyses by selected demographics (age, gender, socioeconomic status (SES)) and by comorbid conditions (hypertension (HTN), diabetes mellitus (DM)).

Results:

Over the study period 423 396 patients presented to an ED with RC. There was a significantly increased risk of RC requiring an ED visit, as ambient temperature increased (comparing daily temperature at 90th percentile vs. the optimal temperature at 10th percentile: RR 1.30; 95%CI 1.20–1.42). Subgroup analysis demonstrated an increased risk from heat for both genders, however, this risk was more pronounced in males (RR 1.36 vs. RR 1.20). In contrast to other age groups, there was an increased risk in those in their 40s (RR 1.42), 50s (RR 1.54) and 60s (RR 1.31). Only the middle SES revealed an increased risk. A history for HTN, but not DM, was associated with an increased risk of RC (RR 2.02).

Conclusions:

Increasing ambient temperature was associated with increased risk of ED visits for RC, particularly in certain demographic subgroups (males, age 40–69 and middle SES) and in those with HTN.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S97.

MP-09.12: Kidney stone analyses in Calgary

Ellen Burgess ¹, Dennis Orton ^1,², David Ward ¹, Hossein Sadrzadeh ^1,²

Abstract

Introduction and Objectives:

As a preparation step to a quality assurance project, an assessment of stone analysis use was conducted by the Clinical Biochemistry Laboratory of Calgary Laboratory Services (CLS).

Methods:

In Calgary, CLS reports kidney stone analyses as percent composition, as determined by infrared spectroscopy. Categorization of the stones was based on composition and determined by which component made up >49% of the total stone content. An assessment of the use of stone analyses was conducted using de-identified data from specimens submitted from January 2010 to September 14, 2015. Descriptive statistics were used.

Results:

During this time frame, there were 14 859 kidney stones submitted for stone analysis from 12 433 patients; 1734 (13.95%) patients had more than one stone analysis performed, accounting for 2431 repeat stone analyses (16.36% of the stone analyses were repeat analyses). Of the patients having repeat stone analyses, 1175 (67.8%) patients had 1559 stones analyzed (64.1%) within one year of the first stone analysis. Within three years of the first stone analysis, 1617 patients (93.3%) had 1229 (92.9%) repeat stone analyses were performed. The majority, 76.2%, of the stones were calcium oxalate stones, 9.8% were calcium phosphate, 9.4% were urate, 0.8% were struvite, and 0.02% were cystine stones; the remainder had mixed composition with no single component making up >49% of the total content. 81.7% of the repeat stone analyses had the same dominant content of stone composition as the initial analysis.

Conclusions:

Overall, the use of repeat stone analysis accounted for one-sixth of the stone analyses and usually was not necessary since the dominant composition of the patient’s stone disease did not change.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S97–S98.

MP-09.13: Efficacy and safety of percutaneous nephrolithotomy

Faisal Khan ¹, A Motiwala ¹, R Keogan ¹, R Jones ¹, R MacDonagh ¹

Abstract

Background:

Percutaneous nephrolithotomy (PCNL) is the recommended treatment option for large-volume renal and staghorn stone disease. To evaluate our success and overall complications rates of PCNL, we recorded complications as per European Association of Urology (EAU) guidelines by using Clavien-Dindo grading system. We also emphasized that even in low-volume centres with fewer number of PCNLs performed every year, we can still achieve the acceptable outcome with fewer complications.

Methods:

A total of 34 patients underwent PCNL from January 2013 to January 2016 at our institute. Demographics, surgical details, and postoperative followup information were obtained to identify stone clearance rates and complications.

Results:

The majority of PCNLs were performed on the left kidney (n=24), with mean stone diameter of 2.2 cm. Overall, eight staghorn, 11 multiple, and 15 single stones were treated. The median body mass index (BMI) of patients was 30. Tract puncture were performed by radiologist with image intensifier. 27 cases were stone-free on fluoroscopy, while residual stones were noted in seven cases. Two were managed with extracorporeal shock wave lithotripsy (ESWL), giving an overall stone free rate of 85%. The remaining stones are managed conservatively. The median length of stay was three days. Complications were recorded as per Clavien-Dindo classification system (Table 1). Majority of patients have no or minor complications. Only five patients (15%) have Clavien Grade 3 complications.

Conclusion:

The modified Clavien system provides a robust system to record complications and their severity more accurately. Our results have shown comparable stone clearance and complication rateswith published evidence. We also have proved that even with smaller no of cases performed, it is safe to perform PCNL in a district general hospital. Therefore, a skilled surgical team and proper equipment are imperative.

Table 1.

MP-09.13. Complications as per Clavien-Dindo grading system

Clavien-Dindo grades	No. of patients	%	Complications
0	13	38%
I	13	38%	Pain, temperature, nausea, bradycardia
II	3	9%	Sepsis, transfusion
III	5	15%	Stent, embolization
IV	0	0
V	0	0

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S98.

MP-09.14: The effect of obesity on perioperative outcomes following percutaneous nephrolithotomy

Vincent Trudeau ^1,², Pierre Karakiewicz ^1,², Paolo Dell’Oglio ¹, Zhe Tian ¹, Luc Valiquette ², Naeem Bhojani ²

Abstract

Introduction and Objectives:

Obesity is on the rise and affects many patients with kidney stones. We hypothesized that obesity predisposes to higher rates of complications and transfusions, longer length of stay (LOS), and higher total hospital charges (THC) after percutaneous nephrolithotomy (PCNL).

Methods:

Within the Nationwide Inpatient Sample (NIS), we identified patients treated with PCNL for kidney stones between 1998 and 2010. Obesity was defined as a body mass index >30 using specific International Classification of Disease, 9th revision, clinical modification (ICD-9-CM) codes. We examined the temporal trends in PCNL use and charges among obese and non-obese patients. We then tested the effect of obesity on peri-operative complications, transfusions, LOS, and THC. LOS and THC were defined as a continuous variable and were also dichotomized according to the 75th percentile into prolonged LOS (pLOS) and increased THC (iTHC). Then, multivariable models adjusted for clustering were fitted.

Results:

Within the NIS, a weighted sample of 90 529 individuals treated with PCNL between 1998 and 2010 was examined. Of those patients, 9300 were obese (10.3%). The proportion of PCNLs performed in obese patients increased throughout the years from 7.4–16.7% (p<0.001). Overall complication rates were 21.6 vs. 22.0% (p=0.3) and transfusion rates were 4.3 vs. 4.0% (p=0.1) for obese and non-obese patients, respectively. Conversely, pLOS (20.9 vs. 18.8%; p<0.001) and iTHC (30.8 vs. 24.4%; p<0.001) were more frequently recorded in obese patients. In multivariable analyses, obesity was not associated with higher rates of overall complications (odds ratio (OR) 0.94; p= 0.3) nor with higher rates of transfusions (OR 0.89; p=0.3). However, obesity was associated with pLOS (OR 1.21; p=0.002), as well as iTHC (OR 1.17; p=0.002).

Conclusions:

PCNL in obese patients did not result in higher rates of individual complications or transfusions. However, from a global perspective, it resulted in higher rates of pLOS and iTHC.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S98.

MP-09.15: From lithotripters to lasers: History of endourology in Canada

Darren T Beiko ¹, Hassan Razvi ², John D Denstedt ², Kenneth T Pace ³, R John D Honey ³, James W Wilson ¹

Abstract

Introduction and Objectives:

The purpose of this study was to report milestones in Canadian endourology, highlighting Canada’s historical contributions to advancements in the field of endourology.

Methods:

A review of the literature was performed from the late 1970’s — the birth of endourology as a subspecialty — to the present. Additionally, recollections by various individuals, including some directly involved, were used in our quest for information on the history of endourology in Canada.

Results:

Endourology was born in Canada when shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy emerged as minimally invasive treatment options for stones in the early 1980s. Dr. Joachim Burhenne, a Harvard-trained radiologist from Germany, first used extra-corporeal shock wave lithotripsy in Canada at the University of British Columbia (UBC) for the treatment of biliary stones. It is believed that the first PCNL was performed at the University of Toronto in the early 1980s. The first use the Swiss Lithoclast for intracorporeal lithotripsy in North America and the first worldwide use of the holmium laser for lithotripsy of urinary tract calculi took place at Western University. Other endourology milestones in Canada include the formation of the Canadian Endourology Group and the emergence of Endourological Society-accredited fellowship programs at the University of Toronto and Western University in the 1990s. Canada hosted the 21st World Congress of Endourology and Shock Wave Lithotripsy annual meeting in Montreal.

Conclusions:

Over the past three decades since endourology emerged in Canada in the 1980s, there have been several milestones in Canadian endourology. Canadian urologists have contributed significantly to advances in the field of endourology and continue to do so. Through the training of the next generation of endourologists at Canadian institutions, the future of endourology in Canada is bright.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S98.

MP-09.16: Body composition and the relationship to patients with large stone burden

Logan W Zemp ¹, Vickie Baracos ², Derek Bochinski ¹, Trevor D Schuler ¹, Timothy A Wollin ¹, Shubha K De ¹

Abstract

Introduction and Objectives:

Computed tomography (CT) body composition (BC) analysis has not been previously described in patients with nephrolithiasis. Objective measurement of decreased muscle surface area (MSA) determines sarcopenia status. Sarcopenia is apredictor of morbidity in oncologic and emergency surgeries. BC has not been studied to determine the effects on 24-hour urine analysis and type stone produced. The objectives of this study were to determine the BC components may predict various stone types, trends in 24-hour urine metabolites, and complication rates.

Methods:

Retrospective review of 152/178 percutaneous nephrolithotomy cases from February 2011–2012. Body composition was analyzed from a single CT slice at the third lumbar level using Slice-O-Matic V4.3 software. Descriptive statistics were used to determine composition parameters and unpaired t-test was used to compare patient quartiles and differences between patient populations.

Results:

Body mass index (BMI) of sarcopenic vs. non-sarcopenic was 28.1 vs. 31.7 (p=0.003). The most prominent type of stones were calcium oxalate (n=84) and uric acid stones (n=31), both of which had mean visceral and subcutaneous adipose tissue cross-sectional areas were elevated compared to calcium phosphate stones. 24-hour urine studies revealed trends of increased Ca, Ox, Na, citrate, and volume in the most muscular quartiles. Increased total adipose tissue was more likely to decrease the pH of the urine. The overall complication rate was 38.2%. Complications occurred in patients with lower mean MSA (132cm² vs. 149cm² p=0.01) and lower mean visceral adipose tissue (151cm² vs. 221cm²).

Conclusions:

Advanced body composition analysis may be a more sensitive predictor of complications associated with PCNL compared to BMI. Also, interesting trends in 24-hour urine collections based on increased MSA will prompt further investigation.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S99.

MP-09.17: Communicating the scans: Are renal stone protocol CT reports giving us enough information?

David Hogarth ¹, Shubha K De ¹, Trevor D Schuler ¹

Abstract

Introduction and Objectives:

Computed tomography (CT) imaging allows for optimal stone management, as it has been shown to improve predictions for spontaneous stone passage and stone-free rates following surgical intervention.¹ The objective of this study is to quantitatively assess CT reporting, in regards to the inclusion of clinically important variables.

Methods:

A review of 100 consecutive renal stone protocol CT scans performed on adult patients from the Alberta Urology Institute was conducted. Descriptive statistics were used to characterize the frequency of each variable included in the CT reports.

Results:

Of 100 stone protocol CT scans, 66 were ordered by primary care physicians (PCP) and 34 by urologists (Urol). Imaging for symptomatic patients were ordered more commonly by PCP (92% PCP, 21% Urol) where as followup scans were more commonly ordered by urologists (6% PCP, 79% Urol). 70 scans identified obstructing stones, 76% of which were ordered by PCP. All 70 reported stone location and size (47% one-dimension, 26% two-dimensions, 27% three-dimensions), two reported stone attenuation, and none reported skin to stone distance. 76 scans reported non-obstructing stone(s); exact number of stones was reported in 72%, estimated in 21%, and omitted in 7% of reports. All 76 reported stone location and size (68% one-dimension, 13% two-dimensions, 5% three-dimensions, 13% estimation only); none reported attenuation or skin to stone distances. Only three reported total radiation dose. Positive or negative findings of hydronephrosis (98%) and hydroureter (80%) were regularly reported, while other findings, such as perinephric standing (41%) and periureteric stranding (16%), were infrequently reported. Some non-urinary tract findings were often reported (bowel in 64%), while others were rarely reported (free air in 15%).

Conclusions:

The indication for stone protocol CT scans change dramatically depending on the ordering physician. Even though consistent reporting of stone number, location, and hydronephrosis occur, other variables, such as stone density, skin to stone distance, and total radiation dose are infrequently reported.

References

1.White. American Urological Association 2012 https://www.auanet.org/common/pdf/education/clinical-guidance/Imaging-Evidence-Report.pdf. Accessed April 27, 2016. [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S99.

MP-09.18: Different incidence of uric acid stone formation in different nationalities

Naimet Naoum ¹, Magdy N Soryal ²

Abstract

Introduction and Objectives:

Different ethnic groups differ in their ability to form stones in different geographical locations. We aimed to study stone formers of different nationalities (Arabs and non-Arabs) living and working in the same city (Alain) in United Arab Emirates (UAE) for the types of stones they form.

Methods:

A retrospective review of patient charts, who presented to a single urology centre, from 2009–2014, with renal, ureteric, vesicle, or urethral stone(s), who were treated medically or surgically and ended with spontaneous passage or surgical extraction. Stones were analyzed using infrared analysis.The variables that were studied included: age, sex, nationality, stone location, and method of stone treatment. Descriptive and Chi-square categorical analysis were used.

Results:

811 stones studied in 712 patients. The average age was 37.5 year. Males constituted 94.2%. For all the studied groups, the most common stone location was the ureter in 58.1%, and the most common treatment modality was extracorporeal shockwave lithotripsy in 46.2%. Mixed stones composed mainly of calcium oxalate monohydrate (CAOXMH) were the most common in 74.7%, followed by dihydrate in 16.3%, uric acid in 7.6%, and few other types. 77.4% of the patients were Asians of different non-Arabic nationalities, who formed mainly CAOX (monohydrate and dihydrate) stones in 91.6%, and uric acid stones in 6.5%. Arabs formed CAOX (monohydrate and dihydrate) stones in 85.5%, and uric acid stones in 12.7%. Non-Arabs more significantly formed CAOXMH stones and less significantly uric acid stones than the Arabs (p=0.03, 0.006, respectively), who otherwise formed more significantly pure uric acid stones (p=0.02).

Conclusions:

From a population who live and work in the same city in UAE, Arabs were found to form more significantly mixed and pure uric acid stones compared with non-Arab stone formers, who more significantly formed CAOXMH stones. Food, type of work, or other personal predisposition factors may all play roles that needs to be further studied.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S99.

UP-09.01: Fluoroscopic radiation exposure in urology: The impact of surgeon-controlled vs. radiation technologist-controlled X-ray exposure

Jeremy G Setterfield ¹, James D Watterson ¹, Matthew Playfair ², Matthew T Roberts ¹, Brian D Blew ¹, J Stuart Oake ¹

Abstract

Introduction and Objectives:

Our study explored the impact of a switch from surgeon-controlled (SC) to radiation technologist (RT)-controlled fluoroscopy on fluoroscopy and operative times. We also aimed to identify other factors that impact fluoroscopy and operative times for ureteroscopy (URS) with laser lithotripsy.

Methods:

Patients undergoing urological procedures requiring fluoroscopy (excluding percutaneous nephrolithotomy (PCNL)) six months before and after the change were identified. Demographic data, disease characteristics, fluoroscopy, and operative times were collected via chart review. Median fluoroscopy and operative times were compared between cohorts. A multivariate analysis was performed to identify factors correlating with fluoroscopy and operative times for URS and laser lithotripsy.

Results:

No significant difference was found between SC (n=206) and RT (n=230) cohorts in regards to median fluoroscopy (58 vs. 56.7 seconds; p=0.3428) or operative (38.5 vs. 36 minutes; p=0.1434) times. For URS with laser lithotripsy, median fluoroscopy and operative times were significantly reduced in the RT cohort (54 vs. 76 seconds; p=0.0028 and 40 vs. 48 minutes, respectively; p<0.0001). Patients undergoing URS alone had a significantly decreased median fluoroscopy time in the SC cohort (47 vs. 73 seconds; p=0.0097). In patients undergoing URS with laser lithotripsy, factors associated with significantly increased fluoroscopy time included male sex, ureteric stent insertion, and flexible ureteroscope or hydrophilic glidewire use. Factors associated with significantly increased operative time included flexible ureteroscope use, large stone size, and difficult ureteric stent insertion.

Conclusions:

Fluoroscopy and operative times are not significantly influenced by who controls fluoroscopy during urological procedures. Patients undergoing URS with laser lithotripsy have decreased fluoroscopy and operative times with RT-controlled fluoroscopy exposure. Patients undergoing URS alone have decreased fluoroscopy times with SC-fluoroscopy exposure.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S99–S100.

UP-09.02: Understanding our failures in getting it up: The prevalence and predictors of failed ureteral access in ureteroscopy

Max Levine ¹, Callum Lavoie ¹, Timothy A Wollin ¹, Trevor D Schuler ¹, Derek Bochinski ¹, Shubha K De ¹

Abstract

Introduction and Objectives:

Failed access (FA) in ureteroscopy (URS) occurs when one is unable to reach the anatomic area of interest for treating symptomatic calculi. This results in aborting a procedure and a return to the operating room, increasing cost and prolonging discomfort. This study’s purpose was to assess rates of FA among our institution’s stone specialists, while attempting to identify preoperative factors associated with FA.

Methods:

Retrospective analysis of 245 consecutive URS performed by three endourologists (January 1 to June 30, 2014) was done with exclusion of diagnostic URS or treatment of non-stone pathology. FA was defined as an inability to advance an ureteroscope (semi-rigid or flexible) to an adequate position for treatment of the stone of interest, requiring the procedure to be aborted. Demographic, anatomic, stone-specific, and intraoperative variables were collected. Descriptive statistics, χ² analysis, and Student’s t-test were used to assess for differences in preoperative factors between successful and FA. Logistic regression was used to identify predictive factors.

Results:

From 245 patients reviewed, 16 (6.5%) FA occurrences were documented. Mean age, gender distribution, and stone size did not differ between the two groups (56 vs. 53 yrs; 56% vs. 52% male; 9.5 vs. 9.1 mm, respectively, N.S.). On χ² or t-test, no variables differed between the groups; rates of stents in situ at the time of URS (6% vs. 25%, p=0.08) approached significance. 19% of FA stones were located in the distal ureter, 37% proximal ureter, 12.5% ureteropelvic junction (UPJ)/renal pelvis, and 30% were intra-renal (6% upper-, 6% mid-, 18% lower-pole). Between surgeons, the rate of FA ranged from 2–9% (p>0.05).

Conclusions:

FA rates in URS are low, but not insignificant (6.5%) among the three stone specialists in our institution. Stones associated with FA were mostly proximal. Our study failed to identify any preoperative parameters predictive of FA. Limitations include the retrospective nature of our data collection, small sample size from a single centre.

References

1.Cetti RJ, Biers S, Keoghane SR. The difficult ureter: What is the incidence of pre-stenting? Ann R Coll Surg Engl. 2011;93:31–3. doi: 10.1308/003588411X12851639106990. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Ji C, Gan W, Guo H, et al. A prospective trial on ureteral stenting combined with secondary ureteroscopy after an initial failed procedure. Urol Res. 2012;40:593–8. doi: 10.1007/s00240-012-0476-0. [DOI] [PubMed] [Google Scholar]
3.Viers BR, Viers LD, Hull NC, et al. The difficult ureter: Clinical and radiographic characteristics associated with upper urinary tract access at the time of ureteroscopic stone treatment. Urology. 2015;86:878–84. doi: 10.1016/j.urology.2015.08.007. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S100.

UP-09.03: DaVinci surgical system’s error during robotic surgeries: Result from largest Canadian multispecialty experience at a single academic institute

Emad S Rajih ^1,², Beatrice Cormier ¹, Vanessa Samoulien ¹, Moishe Lierman ¹, Hugues Widmer ¹, Jean-Baptiste Lattouf ¹, Abdullah M Alenizi ¹, Roger Valdivieso ¹, Pierre-Alain Hueber ¹, Assaad El-Hakim ¹, Kevin C Zorn ¹

Abstract

Introduction and Objectives:

Several studies have reported on the robotic error and faults in the initial era of widespread usage in different surgical disciplines. During that time of first-generation robotic system uses and learning curves, physicians were faced with concerns about surgical robot reliability and errors leading to adverse outcomes.¹ Herein, we report on the latest fourth-generation da Vinci Surgical (Si) System malfunctions and errors.

Methods:

A total of 844 robotic surgeries were performed between October 2012 and October 2015 at our academic centre. All cases were also performed with the same dedicated robotic nursing staff. The three subspecialties using the robot included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, occurrence year, and clinical consequences.

Results:

Overall robotic malfunctions were documented on the DaVinci Si computer console in 2.72% (23/844). The most common error was arm-collision-related in 18 cases (2.13%). Other errors include battery-related in two cases (0.23%), unrecoverable electronic-related in two (0.23%), and illuminator-related in one case (0.11%). Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred due to robotic malfunctions. Furthermore, there was no reported patient injury or death directly related to robotic malfunctions.

Conclusions:

For all the advanced features the da Vinci system offers, it continues to be surprisingly reliable. Throughout our multi-users and multi-specialties experience, device failures did not result in any case conversion or procedure abortion. As such, a low device failure rate can be reported when counselling patients undergoing current robotic surgery. Most importantly, while mechanical and electronic errors can happen, they do not appear to impact surgical outcomes or patient safety.

Table 1.

UP-09.03. Type of instruments failure (Was the arm a failure and could not be used or just a recoverable fault/error?)

Type of failure	Cases (%)
Arm collision related errors	18 (2.13%)
Illuminator related	1 (0.11%)
Battery related	2 (0.23%)
Unrecoverable electronic communication related	2 (0.23%)
Total	23 (2.72%)

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References

1.Zorn KC, Gofrit ON, Orvieto MA, et al. Da Vinci robot error and failure rates: Single institution experience on a single three-arm robot unit of more than 700 consecutive robot-assisted laparoscopic radical prostatectomies. J Endourol. 2007;21:1341–4. doi: 10.1089/end.2006.0455. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S100–S101.

UP-09.04: External lower abdominal pressure to aid semi-rigid ureteroscopy in the proximal ureter: Opinion of modern era endourologists, is it safe and effective?

Monica A Farcas ^1,², Daniela Ghiculete ¹, Keith P Barrett ^1,², Robert J Sowerby ^1,², Kenneth T Pace ^1,², R John D Honey ^1,²

Abstract

Introduction and Objectives:

In 2005, we described the technique of applying external abdominal pressure (EAP) to allow semirigid ureteroscopy (SURS) above the iliac vessels.¹ This led to attempted treatment of all ureteric calculi at our centre with SURS. In this study, we survey modern-era endourologists about their use of this technique. Furthermore, we present our experience with the technique’s safety and efficacy.

Methods:

In 2009, a survey was circulated to the Endourological Society inquiring about use of EAP in SURS. In 2013, the survey was re-circulated to those unfamiliar with the technique in 2009, following provision of its reference. Retrospective chart review included all upper- and mid-ureteric calculi treated with SURS at our centre from 2012–2014 with radiologic followup of at least three months. Access difficulties, intraoperative complications, stone clearance, and ureteral stricture rates were reviewed.

Results:

282 endourologists responded to the 2009 survey. 51 (18%) regularly used EAP for SURS. In 2013, re-survey of the 231 urologists who had not used this technique yielded a 43% response rate, with 23 having attempted it and 16 planning to continue to using it. Of 519 URSs performed between 2012 and 2014 at our centre, 75 met study criteria. EAP was used in all cases as deemed necessary. In 91% of cases, the ureter was accessed without difficulty. Five (6.7%) conversions to flexible URS were required due to a tortuous or narrow ureter. Two patients (2.7%) were stented due to narrow ureter, and planned for SURS at a later date. There were no ureteric injuries due to SURS over the iliac vessels or psoas muscle. No patients developed ureteric strictures requiring intervention.

Conclusions:

Eight years after publication of a technique for using EAP to aid SURS in the upper ureter, only a minority of endourologists have adopted it. At our centre, this technique continues to be the standard of practice, with excellent success rates and minimal complications.

References

1.Dagnone AJ, Blew BD, Pace KT, et al. Semirigid ureteroscopy of the proximal ureter can be aided by external lower-abdominal pressure. J Endourol. 2005;19:342–7. doi: 10.1089/end.2005.19.342. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S101.

UP-09.05: Compliance of the recurrent renal stone former with current best practice guidelines

Derek Bos ¹, Jennifer Hoogenes ¹, Kevin Kim ¹, Shahid A Lambe ¹, Bobby Shayegan ¹, Edward D Matsumoto ¹

Abstract

Introduction and Objectives:

Patient compliance to best practice guidelines is a significant factor in renal stone prevention. Patient compliance has historically been poor. As a result, it has seen increasing attention in the medical literature. However, there remains a paucity of data in the renal stone setting. We evaluated the recurrent renal stone formers’ compliance with current Canadian Urological Association (CUA) best practice guidelines.

Methods:

Recurrent renal stone former patients were consecutively recruited during urology clinic at our institution. Participants completed a one-time questionnaire that was developed in accordance with CUA renal stone best practice guidelines. Questionnaire sections included: 1) demographics; 2) interaction(s) with and satisfaction of encounters with primary care physicians and urologists; and 3) knowledge and compliance with best practices.

Results:

A total of 191 patients were enrolled in the study; 56% were men, 67% had a positive history of stone surgery, and 22% had a family history of stone disease. Participants perceived satisfactory knowledge translation with their urologist and primary care physician 83.5% and 62.1% of the time, respectively (p<0.05). Patients perceived their disease as severe 22% of the time, while their belief in the utility of preventative stone measures was 65%. Overall, patient compliance with CUA best practice guidelines was 46%; the majority of patients (70%) complied with high fluid intake, the most critical stone-inhibitory practice.

Conclusions:

Practice compliance of the recurrent stone former was relatively low in this patient sample, which is consistent with previous studies. The low compliance rate may be attributed to insufficient knowledge translation, lack of perceived disease severity, and/or patient uncertainty regarding the value of preventative stone practices.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S101.

UP-09.06: 60-day outcomes after early surgical intervention vs. medical treatment of ureteric stones causing acute renal colic

Taylor E Remondini ¹, Grant Innes ², Anthony J Cook ¹, Parthiv Amin ¹, Samir Sami ¹, Riley Simister ¹, Dean Wong ¹, Bryce A Weber ¹

Abstract

Introduction and Objectives:

Renal colic is a common condition, affecting up to 10% of the population. Patients frequently present to the emergency department (ED) requiring rapid care and aggressive symptom management. Therefore, we wish to evaluate a large cohort of renal colic patients in a high-intervention setting to determine their characteristics.

Methods:

This multicentre administrative database study retrospectively reviewed the all Calgary patients with an ED diagnosis of renal colic between January 1, 2014 and December 31, 2014. Tests and treatments were captured from the order entry database, and ED revisits, admissions, and interventions from the discharge abstract database.

Results:

Of 3104 renal colic visits, 921 (29.7%) had an index surgical intervention and 2183 (70.3%) were managed medically. 1850 (59.6%) had imaging-confirmed ureteric stones, with 752 (40.6%) of these patients receiving surgery at an index visit. Patients were more likely to have surgery if they had a proximal ureteric stone (OR 2.18; p<0.001), stone larger than 5 mm (OR 4.38; p<0.001), or hydronephrosis (OR 2.81; p<0.001). Of these proximal stone patients, the ones that received surgical intervention at the index visit were less likely to require surgical procedures within 60 days of the index visit (OR 0.52; p=0.006). Patients with stones that are larger than 5 mm in diameter are more likely to revisit the ED (p=0.003), be admitted to the hospital (p=0.06), and undergo a procedure within 60 days (p=0.008). Out of patients with these larger ureteric stones, 412 (63.7%) went on to receive surgery at the index visit. If a patient with a larger stone received a surgery at the index visit, they were less likely to have surgery (OR 0.48; p=0.002), yet more likely to be admitted (OR 1.91; p=0.007) within 60 days of the index visit.

Conclusions:

Patients with proximally located ureteric stones or stones larger than 5 mm in diameter were more likely to have surgeries to treat their colic. Proximal stone patients treated with surgery were less likely to have to return to the hospital to have a procedure performed within 60 days of the index visit. Patients with stones larger than 5 mm who received surgical intervention at the index visit were less likely to have to undergo a future surgery.

Acknowledgments

MSI Foundation, Edmonton, AB

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S101.

UP-09.07: Intraoperative radiographic determination of ureteric length as a method of determining ideal stent length

Keith P Barrett ¹, Daniela Ghiculete ¹, Monica A Farcas ¹, Robert J Sowerby ¹, Kenneth T Pace ¹, R John D Honey ¹

Abstract

Introduction and Objectives:

Accurate determination of ureteric length and appropriate stent length remains a challenge. The objective of this study was to describe an intraoperative technique to measure ureteric length and determine appropriate stent length, and to compare this technique to other methods of determining ureteric length.

Methods:

Patients undergoing ureteroscopy requiring postoperative stenting were prospectively identified. Gender, age, height, body mass index (BMI), and lumbar height on computed tomography (CT) were recorded. Ureteric length was measured using four methods: direct measurement with a ureteric catheter (ULdir), ureteropelvic junction (UPJ) to uretero-vesical junction (UVJ) distance on axial and coronal CT, and using an intraoperative radiographic technique. To perform the radiographic measurement, the cystoscope was positioned at the UVJ. A metal bead was affixed to the skin over the UVJ. An angiographic catheter with radiopaque markings at 1 cm intervals was positioned at the UPJ. Ureteric length was the distance from the UPJ to the bead measured using the catheter markers. Correlation between ULdir and the recorded variables and methods of ureteric length measurement were calculated. Stent length was chosen based on radiographic measurement, and was appropriate if it demonstrated a proximal coil in the renal pelvis and a distal coil in the bladder not crossing midline.

Results:

18 ureters were included. Radiographically measured ureteric length was most strongly correlated with ULdir (r=0.833; p< 0.01). Coronal CT ureteric length was also significantly associated with ULdir (r=0.569; p=0.01). Height, CT axial ureteric length, and lumbar height were not significantly associated with ULdir. Stents were of appropriate length in 17/18 cases.

Conclusions:

Radiographic ureteric length measurement was strongly correlated with directly measured ureteric length. A length of stent chosen based on radiographic ureteric length resulted in an appropriate stent length.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S102.

MP-10.01: Neuromuscular stimulation leads to improved lower limb edema and blood flow compared to standard compression devices following kidney and pancreatic transplantation

Bijad Alharbi ¹, Omar Ali ¹, Patrick P Luke ¹, Alp Sener ¹

Abstract

Introduction and Objectives:

Kidney and pancreas transplant recipients undergo significant fluid shifts in the postoperative period, leading to significant lower limb edema. Intermittent compression (IPC) devices are used to reverse the edema, however, many factors may limit the use of IPC units. The Geko Plus device is an internally powered calf neuromuscular stimulator, which has previously been shown to have beneficial effects in improving blood flow. Its role in transplantation has not previously been assessed. Our objective was to prospectively evaluate the effects of IPC and Geko Plus devices on lower limb edema in renal and pancreatic transplant patients.

Methods:

We performed a prospective, randomized, controlled, single-centre, study where 30 patients were randomly assigned to wear IPC (Group1, n= 16) or the Geko Plus device (Group 2, n=14) postoperatively until Day 6 after surgery. We measured patient weight and lower leg and thigh circumferences daily. Ultrasound Doppler of the allograft and of the lower limbs was carried out on postoperative Days 1 and 5 to assess venous flow and velocity in the femoral vein. Also, we monitored total urine output, serum creatinine levels.

Results:

Median age of the recipients was 50 (24–72) years and 66% were male. 27 patients underwent kidney transplantation and three underwent kidney and pancreas transplantation. There were no differences in the body mass index (BMI) of the recipients in either group. Donor types were as follows: Group 1: 4 DCD, 7 NDD, 5 LD; and Group 2: 4 DCD, 7 NDD, 3 LD. We observed a significant increase in calf circumference following transplantation in Group 1 by 7.2% (2.3 +/− 2 cm) compared to Group 2, which showed no change from baseline (0.13%, 0.05 +/− 0.95 cm; p<0.0001). Thigh circumference also followed a similar trend, with only Group 1 showing a significant increase (5.5%, 2.4 +/− 2 cm) from baseline compared to Group 2 (p<0.001). Doppler ultrasound showed a remarkable increase in mean flow velocity in the Geko Plus patients of 19 cm/s, whereas the IPC patients showed lower velocities 11cm/s (p<0.0005). There was no significant difference between groups in serum creatinine, weight change, urine output, and resistive index of the allograft. There were no complications in either group.

Conclusions:

We report, for the first time, that the use of the Geko Plus device in the immediate postoperative period leads to an improvement in lower limb edema and in venous flow in kidney and pancreas transplant recipients compared to standard IPC.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S102.

MP-10.02: National renal transplant outcomes in paediatric and young adult patients in the Republic of Ireland

Fardod O’Kelly ¹, Claire Kennedy ¹, Patrick O’Kelly ¹, Richard Power ¹, Declan de Freitas ¹

Abstract

Introduction and Objectives:

Pediatric and young adult kidney transplant recipients have complex and dynamic medical and psychosocial care needs. This national review aimed to describe the epidemiology of transplantation in the two groups over time and to compare post-transplantation outcomes and issues between the two groups.

Methods:

The Irish national kidney transplant database was accessed to identify all pediatric (recipients aged 0–17 years; Group 1) and young adult (recipients aged 18–26 years; Group 2) kidney-only transplants performed between January 1, 1990 and December 31, 2014. Medical records, laboratory results, and histology reports were reviewed. Statistical analysis was performed using STATA version 13.1.

Results:

485 patients received 561 kidney-only transplants. No patients were lost to followup. In Group 1 (n=261 transplants), the most common cause of end-stage kidney disease (ESKD) was congenital abnormality of the genitourinary tract. 56 (21%) of the transplants were biopsied and 21 (8%) had biopsy-proven acute rejection (BPAR). 300 transplants were performed in Group 2. Glomerulonephritis and reflux nephropathy were the most frequently encountered causes of ESKD. 133 (44%) were biopsied and 50 (16.6%) had BPAR. Both patient groups had an identical graft half-life of 13.6 years. There were five cases of malignancy in Group 1; three cases of post-transplant lymphoproliferative disease and two cases of squamous cell bladder cancer. Two patients in Group 2 developed malignancy during the period of followup, both in their native kidneys. Nine (3.4%) pediatric patients and 13 (4.3%) young adult patients died during the period of followup.

Conclusions:

The journey to transplantation and the approach to post-transplant care differed between pediatric and young adult transplant recipients; despite this, graft survival was remarkably similar. Meticulous attention to detail, including appropriate malignancy screening, is required when caring for these patient cohorts.

References

1.Bobanga ID, Vogt BA, Woodside KJ, et al. Outcome differences between young children and adolescents undergoing kidney transplantation. J Pediatr Surg. 2015;50:996–9. doi: 10.1016/j.jpedsurg.2015.03.021. [DOI] [PubMed] [Google Scholar]
2.Yamada A, Tashiro A, Hiraiwa T, et al. Long-term outcome of pediatric renal transplantation: A single-centre study in Japan. Pediatr Transplant. 2014;18:453–62. doi: 10.1111/petr.12299. [DOI] [PubMed] [Google Scholar]
3.Van Arendonk KJ, Boyarsky BJ, Orandi BJ, et al. National trends over 25 years in pediatric kidney transplant outcomes. Pediatrics. 2014;133:594–601. doi: 10.1542/peds.2013-2775. [DOI] [PMC free article] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S103.

MP-10.03: Comparison of open and laparoscopic living donor nephrectomies: A Canadian single-centre experience

Christie Rampersad ¹, Clare E Gardiner ¹, Joshua Koulack ², Thomas B McGregor ¹

Abstract

Introduction and Objectives:

Laparoscopic donor nephrectomy is the standard for living kidney donation. Benefits of the laparoscopic over open approach include shorter length of stay, decreased postoperative pain, and shorter return to work. We performed a retrospective analysis of our single-centre donor nephrectomy series with regard to operative approach and donor and recipient outcomes.

Methods:

Following ethics approval, we retrospectively reviewed 89 consecutive open donor nephrectomies (ODN) and 83 consecutive laparoscopic donor nephrectomies (LDN) from 2007–2015. In total, 344 patients were reviewed, including donor and recipient pairs. Donor and recipient demographics, outcomes, complications, and financial cost were assessed and compared between the two approaches.

Results:

172 donor nephrectomies were reviewed. Estimated blood loss (EBL) was higher for ODN, with a mean loss of 285.7 mL compared to 66.9 mL for LDN. The rate of intraoperative complications was higher for ODN. Transfusion requirements and warm ischemia time (WIT) were comparable. Operative time was longer for LDN, with a mean operative time of 165.9 minutes compared to 108.4 minutes for ODN. Postoperatively, length of stay was longer for ODN by one day. Postoperative complications confined to Clavien-Dindo Grades 1–2 and overall rate was comparable between surgical approaches. Donor creatinine at discharge was higher for ODN, but unlikely clinically significant. Overall cost of LDN was $684 higher for an uncomplicated admission. With regard to recipient allograft outcomes, rate of delayed graft function and recipient 12-month creatinine were comparable for ODN and LDN.

Conclusions:

This single-centre analysis demonstrates advantages of LDN, including lower blood loss, fewer intraoperative complications, and shorter hospital stay. Introducing the LDN locally has improved important donor parameters while maintaining comparable allograft outcomes.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S103.

MP-10.04: Transplanting the high-risk pediatric end-stage renal disease population: An anticoagulation protocol to reduce renal graft loss secondary to thrombosis

Byron Dubow ¹, Marshall Shaw ¹, Daniel Tinker ¹, Blake Palmer ¹, Puneet Sindhwani ¹

Abstract

Introduction and Objectives:

Thrombosis is an early cause of allograft failure in the pediatric transplant population. This study examines the efficacy of a risk-stratified anticoagulation protocol (AP) in allogenic renal transplantation in a pediatric end-stage renal disease (ESRD) population. The protocol consists of a thrombophilia laboratory panel (TP), past medical history, and family history. Fig. 1 details the TP. Risk stratification for post operative anticoagulation was done at the time of listing per Fig. 2.

Methods:

Patients who underwent renal allograft transplantation between January 2005 and August 2015 were selected from The Children’s Hospital of Oklahoma transplant database. 15 allografts preceded the AP and 75 cases followed. Allograft failure and bleeding-related complication data were collected during a minimum follow up period of 3–6 months, the latter in patients on extended anticoagulation. A root cause analysis categorized the etiology of allograft failures. One of four staff surgeons performed all surgeries; each used standard renal transplant technique. Chi-square tests, Fisher’s exact tests, and Student’s t-tests were used, as appropriate, to analyze the data.

Results:

Graft failure secondary to thrombosis occurred in three of 15 cases (20%) in the pre-protocol group compared to 0 of 75 cases in the post-protocol group; this difference was statistically significant (p=0.004). There were no bleeding complications necessitating transfusion or exploration (p=1.000).

Conclusions:

The risk category-based AP was associated with decreased incidence of renal allograft losses secondary to thrombosis. Targeted use of anticoagulation therapy did not significantly increase the risk of bleeding-related complications following renal transplant in an ESRD pediatric population.

Table 1.

MP-10.04. Thrombophilia panel (TP)

Factor V leiden

Prothrombin gene mutation

MTHFR mutation

Anti-phospholipid antibodies (Lupus anticoagulant)

Protein C levels and activity

Protein S levels and activity

Antithrombin III activity

Homocysteine levels

Factor VIII activity^*

Lipoprotein a levels

Dysfibrinogenemia^*

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^*

Factor VIII activity and assays for dysfibrinogenemia were dropped from the TP in 2008 as their utility was not supported by ongoing literature reviews.

Table 2.

MP-10.04.

Risk level	TP	Management
1- High-risk	Positive TP (other than MTHFR); PMH of thrombosis	Heparin postoperative, LMWH BID for 6 months
2- Moderate-risk	Positive TP (other than MTHFR) + FH of thrombophilia + MTHFR + homocysteinemia (no PMH of thrombosis)	Heparin postoperative, LMWH BID for 3 months, LMWH QD for 3 months
3- Low-risk	MTHFR + homocysteinemia	Heparin postoperative LMWH QD for 3 months
4- No-risk	No thrombophilia hx	No anticoagulation

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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S103–S104.

MP-10.05: Age effect in donation after cardiac death donor renal allografts: Prediction and comparison of outcomes

David M Mikhail ^1,², Jingwen Chen ², Hemant Sharma ³, Patrick P Luke ^1,², Alp Sener ^1,²

Abstract

Introduction and Objectives:

Since its acceptance in North America, donation after cardiac death (DCD) donors have become an increasingly common source for organ transplantation. The most commonly used tool to predict graft function is the complicated Kidney Donor Risk Index/Kidney Donor Profile Index (KDRI/KDPI), which uses 10 variables to predict outcomes. We assessed the United Network for Organ Sharing (UNOS) database to determine if age < or > 50 is sufficient to predict functional graft outcomes.

Methods:

Donor and recipient data for transplants carried out between 2005 and 2010 was obtained from the UNOS database, which was complete to March 2013. Patients with incomplete KDRI-required variables were excluded. For KDRI and KDPI analysis, the scaling factor of 1.22 for 2010 was used. Univariate and multivariate analysis was performed.

Results:

Overall, 1832 DCD >50 and 4968 DCD <50 donors were analyzed. Recipient age was 56 vs. 50 (p<0.05) for these groups. Mean donor ages were 55 ± 4 and 31 ± 12, respectively. Calculated median KDPI were 37% and 74% for <50 and >50 groups, respectively. These predicted one-, three-, and five-year graft survival of 91%, 82%, and 71% compared to 86%, 73%, and 60% in the two groups, respectively. Delayed graft function was significantly higher in the DCD >50 group (49% vs. 37%; p<0.05). In both groups, DGF correlates with inferior graft survival (p<0.05). There was a significant difference in graft survival between the two groups (p<0.05). Multivariate analysis showed recipient age to be the most significant factor correlated with graft survival in both groups (p<0.05).

Conclusions:

Age >50 years in DCD renal allograft donors leads to significantly increased DGF rates and decreased graft survival. Further comparison needs to be performed for neurologic brain death and living donors to better assess the age effect on renal allograft survival in those groups.

References

1.Rosengard BR, Feng S, Alfrey EJ, et al. Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor. Am J Transplant. 2002;2:701–11. doi: 10.1034/j.1600-6143.2002.20804.x. [DOI] [PubMed] [Google Scholar]
2.Matas AJ, Smith JM, Skeans MA, et al. 2015. OPTN/SRTR 2013 Annual data report: Kidney. Am J Transplant. 2015;15:1–34. doi: 10.1111/ajt.13195. [DOI] [PubMed] [Google Scholar]
3.Akkina SK, Asrani SK, Peng Y, et al. Development of organ-specific donor risk indices. Liver Transpl. 2012;18:395–404. doi: 10.1002/lt.23398. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Rao PS, Schaubel DE, Guidinger MK, et al. A comprehensive risk quantification score for deceased donor kidneys: The kidney donor risk index. Transplantation. 2009;88:231–6. doi: 10.1097/TP.0b013e3181ac620b. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S104.

MP-10.06: The fate of postoperative perinephric fluid collections within one month of pediatric renal transplantation: Etiology and and therapeutic interventions

Frank J Penna ¹, Armando J Lorenzo ¹, Walid A Farhat ¹, Darius J Bagli ¹, Martin A Koyle ¹, Rakan Odeh ¹

Abstract

Introduction and Objectives:

Postoperative perinephric fluid collections after pediatric renal transplantation (RT) are common and may include clinical entities such as urinoma, hematoma, and lymphocele. Such collections are usually monitored with serial ultrasounds. Size, etiology, and/or the presence of symptoms dictate the need for intervention. We hypothesized that these fluid collections rarely require intervention and gain little benefit from close followup with imaging in the presence of stable clinical status (asymptomatic with stable renal function) with no hydronephrosis.

Methods:

All children undergoing pediatric RT at our institution within the last five years (2010–2014) were retrospectively reviewed within one month postoperatively. Perinephric fluid collections on postoperative renal ultrasounds were measured by total volume and correlated with clinical parameters and symptomatology. Indicated interventions including image-guided drainage and surgery were captured.

Results:

103 children underwent RT (59 deceased and 44 living-related donor) over this period, with mean age of 10.6 ± 5.4 years. Only 37 patients (36%) had no perinephric collections on ultrasound at two weeks postoperatively. 66 patients (64%) had fluid collections, 14 of whom underwent intervention: nine lymphoceles (8.7%), three infected hematomas (2.9%), and two urinomas (1.9%). Four patients with lymphoceles underwent laparoscopic marsupialization after failed drainage and/or sclerotherapy. The average fluid collection volume was 169 cm³ 618 cm³ in the intervention group compared to 46 cm³ in those observed.

Conclusions:

Perinephric fluid collections are common after pediatric renal transplantation, the majority of which do not require intervention. Larger volume fluid collections were associated with intervention and usually are secondary to lymphoceles.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S104–S105.

MP-10.07: Keeping renal transplant within urology: The success of a hybrid practice model in Canada

Andrea Kokorovic ¹, Neal E Rowe ²

Abstract

Introduction and Objectives:

Canadian renal transplant urologists have practice patterns that range across various urological disciplines. There remains a dichotomy with regards to who should perform renal transplants in Canada, as both urologists and general surgeons are involved in renal transplantation surgery. This study aims to elucidate the practice patterns of Canadian transplant urologists, their training backgrounds, and opinions regarding the future of renal transplantation within Canadian urology.

Methods:

We performed a 39-item online survey directed to transplant urologists currently practicing in Canada. Participants were contacted via e-mail and given 88 days to complete the survey. The response rate was, on average, 52% per question. Descriptive statistics were used.

Results:

Survey responses were obtained from transplant urologists across Canada. Most respondents completed their fellowship in Canada or the United States within the last 10 years. 63% of respondents considered transplantation their primary fellowship subspecialty, and the most common secondary subspecialty was minimally invasive surgery (MIS)/robotics. Likewise, the majority of respondents cited MIS/robotics as being their non-transplant practice focus. Most Canadian transplant urologists are involved in research, however, less than half cite transplantation as their primary research focus. 81% believe that urologists should be performing renal transplantation in Canada.

Conclusions:

Canadian transplant urologists run a hybrid practice, into which they incorporate both transplantation and various other urological disciplines, the most common being MIS/robotics. This provides a framework for implementing fellowships for transplantation combined with other subspecialty skills. This approach broadens trainee recruitment and increases the marketability of fellowship trainees. This may further promote the conservation of renal transplantation at urology departments in both Canada and abroad.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S105.

MP-10.08: The importance of resident exposure to renal transplant: A comparative analysis of surgical trainees

Jennifer Bjazevic ¹, Sebastian Launcelott ², Shannon Stogryn ³, Jasmir (Jay) G Nayak ⁴, Thomas B McGregor ¹

Abstract

Introduction and Objectives:

In Canada, urologists and general and vascular surgeons preform renal transplantation. However, recent studies have shown a declining role of urology in transplant. We examined the current exposure of surgical trainees to transplant and how this may impact the future composition of transplant surgeons, and comparatively the role of urology in transplant.

Methods:

An anonymous questionnaire was devised to assess resident exposure and opinions relating to renal transplantation and was administered to Canadian general and vascular surgery trainees. All responses were graded on a validated five-point Likert scale. Descriptive statistics and Pearson’s Chi-squared test were used to analyze the responses.

Results:

67 surgical trainees completed the survey. Non-urology trainees had limited exposure to both renal transplant and laparoscopic donor nephrectomy, with only 35.6% and 26.4% of general surgery, and 15.4% and 0% of vascular surgery residents, respectively, having experience. A minority of general (3.8%) and vascular surgery (0%) trainees had plans for a transplant fellowship. The intent to pursue further training in transplant was correlated to the amount of exposure that residents received during their training (r=0.42; p<0.0001).

Conclusions:

Vascular and general surgery trainees have limited exposure to transplant and consequently minimal interest in pursuing careers in transplant. Comparatively, urology residents have a much greater exposure to transplant, with 77.4% of residents having experience with both transplant and laparoscopic donor nephrectomie.¹ This corresponded with urology trainees expressing a greater interest in pursuing fellowship training in transplant (9.7%).¹ Consequently, a continued strong exposure to transplant during residency is essential to ensure that urology continues to be highly involved with renal transplant.

References

1.Bjazevic J, McGregor T. Current perspectives of urology involvement in renal transplantation: A survey of Canadian senior residents. Urol Pract. 2015;2:275–80. doi: 10.1016/j.urpr.2015.03.001. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S105.

MP-10.09: Early radiographic and histologic findings in delayed graft function

Mena Bishay ¹, Max Levine ¹, Trevor D Schuler ¹

Abstract

Introduction and Objectives:

Thorough monitoring of the renal transplant patient is key in reducing adverse outcomes. Routine imaging in the postoperative period may detect allograft abnormalities, which can be an early sign of complication. Delayed graft function (DGF) is a complication of renal transplant that is associated with increased graft loss and mortality.¹ This study seeks to investigate the possible role of routine diagnostic imaging and intraoperative biopsy in predicting DGF.

Methods:

A retrospective analysis was performed on 213 renal transplants done at the University of Alberta Hospital. Clinical data, including creatinine (Cr) values, postoperative dialysis, renal ultrasound and (99 m) Tc-mercaptoacetyltriglycine ((99m)Tc-MAG3) renal scan reports, and renal biopsy reports were recorded from the first postoperative week. Patients with DGF were identified and matched by age, gender, and donor type. Statistical comparisons between DGF and normal graft function were made using McNemar’s test.

Results:

74 patients were included in this study. Patients with DGF were more likely to have acute tubular necrosis (ATN) in (99 m) Tc-MAG3 (100% vs. 58%; p<0.001), evidence of ATN on intraoperative renal biopsy (52% vs. 27%; p<0.05), and elevated resistive indices on renal ultrasound (83% vs. 42%; p<0.05) compared to those with normal graft function. Of those transplants from donations after brain death (n=57), patients with DGF were more likely to have ATN in nuclear medicine studies (100% vs. 66%; p<0.005) when compared to normal graft function.

Conclusions:

There are higher rates of radiologic and histologic findings in renal transplant patients with DGF when compared to those with normal graft function. This may potentially offer a useful parameter for assessment in the diagnosis of DGF. However, future studies should be performed to more thoroughly investigate the relevance of these findings in the setting of DGF.

References

1.Butala NM, Reese PP, Doshi MD, et al. Is delayed graft function causally associated with long-term outcomes after kidney transplantation? Instrumental variable analysis. Transplantation. 2013;95:1008–14. doi: 10.1097/TP.0b013e3182855544. [DOI] [PMC free article] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S105.

MP-10.10: A novel technique to preserve an accessory lower pole artery in renal transplantation

Luke F Reynolds ¹, Annie-Claude Blouin ¹, Jeffrey Warren ¹, Michael Odell ², Brian D Blew ¹

Abstract

Introduction and Objectives:

One-third of donor kidneys have anatomic anomalies, such as a lower pole artery (LPA). Revascularization of LPA is important to avoid complications, such as graft failure, ureteric necrosis, postoperative hypertension, calyceal fistula formation, and segmental renal infarction. End-to-side anastomosis to the main renal artery (MRA) is a commonly used technique, however, this may compromise the graft function. The use of the inferior epigastric artery (IEGA) is a viable option with good outcomes.¹ In this paper, we present a novel technique for anastomosing the LPA to the IEGA.

Methods:

A 54-year-old male underwent transplantation of a left kidney into the right iliac fossa. The vascular anastomoses were performed in the standard end-to-side fashion onto the external iliac artery (EIA), with the exception that the ipsilateral IEGA was dissected and preserved to a length of 12 cm from its origin. After unclamping, the lower pole remained devascularized. The caliber of the LPA was measured at 2.5 mm and was slightly smaller than the IEGA. Both vessels were prepared using the operating microscope. A coupling system (Synovis Canada) was employed, using 2.5 mm coupler rings, for the arterial anastomosis. Two 8-0 nylon interrupted sutures were placed around the coupling device ring for added tensile strength.

Results:

Once the clamps were removed from the LPA, the lower pole was immediately well-perfused. Also, peristalsis of the allograft ureter, intraoperative urine output, and peri-ureteric bleeding improved.

Conclusions:

Anastomotic microvascular devices are commonly used in reconstructive surgery for anastomosing veins comparable in size to accessory arteries of the kidney. This technique does not require reconstruction of the MRA, allows rapid coupling of the second artery, manages vessel size discrepancies well, and may decrease risk of thrombosis compared to hand-sewn, end-to-end anastomosis of the IEGA to a segmental vessel.

References

1.Antonopoulos IM, Yamaçake KG, Oliveira LM, et al. Revascularization of living-donor kidney transplant with multiple arteries: Long-term outcomes using the inferior epigastric artery. Urology. 2014;84:955–9. doi: 10.1016/j.urology.2014.06.022. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S106.

MP-10.11: Elevated C-peptide levels are associated with acute rejection in patient undergoing simultaneous kidney pancreas transplantation

Wen Y Xie ^1,², Vivian McAlister ^2,³, Kyle Fiorini ¹, Alp Sener ^1,², Patrick P Luke ^1,²

Abstract

Introduction and Objectives:

There are few biomarkers that can predict rejection or organ failure in simultaneous kidney pancreas (SPK) transplant recipients. We hypothesized that stability of insulin or C-peptide production from the transplanted pancreas could predict impending graft rejection or failure.

Methods:

Patients who had undergone SPK transplantation with a minimum of five years of followup were identified. C-peptide levels were routinely obtained during clinic visits. Return to dependence on insulin therapy or return to dialysis was used to define pancreas and kidney graft failure, respectively. Protocol biopsies of the kidneys were performed at 3–6 and 12 months as a routine. For cause biopsies were also performed. Renal allograft biopsy results were categorized as no rejection/borderline changes, or acute rejection.

Results:

Between January 2004 and December 2010, 38 SPK transplants were performed. Eight patients were excluded due to early graft failures (thrombosis, leaks), death, and inadequate data. 11 patients had acute rejections detected on biopsy. C-peptide levels drawn prior to documented rejections were significantly higher in patients with acute rejection than in patients with borderline/no rejection (p=0.007). Mean time period between C-peptide level and biopsy was 49 days for acute rejections and 55 days for borderline/no rejections. In addition, patients who has had at least one episode of acute rejection continued to have higher C-peptide levels at one and five years post-transplant (p<0.001, p<0.001) vs. borderline/no rejection. C-peptide instability as measured by high delta C-peptide levels was also predictive of rejection (p<0.001). In total, four patients had graft losses over the followup period. Four patients suffered five graft losses (one kidney, two pancreas, and one combined). No difference in C-peptide level or differences in C-peptide variability were noted in patients with functional grafts vs. those suffering graft losses.

Conclusions:

SPK patients with acute rejection had higher C-peptide levels prior to biopsy vs. non-rejectors. Patients demonstrating C-peptide variability were associated with a higher risk of rejection. Further study is required to determine whether C-peptide levels can be used as a bio-marker to predict rejection.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S106.

MP-10.12: Assessment of eGFR and one-hour biopsy using in-situ cooling double-balloon catheters in deceased kidney transplants

Kazuo Mizutani ^1,², Ryohei Hattori ², Tsuneo Kinukawa ³, Osamu Kamihira ⁴, Momokazu Gotoh ²

Abstract

Introduction and Objectives:

The shortage of deceased donor kidneys for transplantation has become a worldwide issue in the past decades. However, both availability and feasibility of marginal deceased donor kidneys are still problematic. To increase donor pool, we created a specially designed in-situ cooling system. The purpose of this study was to estimate availability of deceased donor kidneys, analyze donor one-hour biopsy, and better evaluate methods to estimate donor/recipient kidney function other than using donor creatinine (Cr), comparing with living related transplants.

Methods:

We studied 129 deceased renal transplant recipients (DD) who received kidneys from non-heart-beating donors beginning in 1984. Donors were in Maastricht Donor Categories III and IV and to minimize warm ischemic kidney damage we performed in-situ cooling with specially designed double-balloon catheters. 29 living-related transplants (LD) were a control group.

Results:

In the DD group, average donor Cr and estimated glomerular filtration rate (eGFR) levels at admission were 0.3–2.1mg/dl (average 1.0) and 24–138 ml/min/1.73 (average 67) and levels before death were 0.3–15.9 (2.7) and 4–164 (34). Average recipient Cr and eGFR levels at discharge were 0.3–5.3 (1.8) and 0.10–133 (39). To define kidney function after transplant, the DD were classified according to recipient eGFR at discharge: <25 for the poor function group (PF: n=32) and >25 for the good function group (GF: n=95). GF had higher eGFR levels at donor hospital admission than the PF (p=0.005). There was no statistically significant difference in Cr levels of donor (at admission and before death) between those groups. Pathologically, the DD with less glomerular sclerosis of one-hour biopsies had better graft survival than damaged subjects (p=0.015). Other histological scores were not associated with kidney survival.

Conclusions:

Deceased kidney transplants had excellent renal function with our double-balloon catheter system. Compared with donor Cr levels, eGFR and one-hour biopsy could be useful for donor evaluation and transplant renal function.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S106.

MP-10.13: A randomized, prospective comparison of pure laparoscopic and laparoendoscopic single-site plus one-port donor nephrectomy

SaeWoong Choi ¹, U-Syn Ha ¹, Sung-Hoo Hong ¹, Ji Youl Lee ¹, SaeWoong SW Kim, Hyuk Jin Cho ¹

Abstract

Introduction and Objectives:

The purpose of this study was to present a comparison between pure laparoscopic and laparoendoscopic single-site plus one-port donor nephrectomy (LESSOP-DN) with respect to clinical outcomes, cosmetic results, and short-term recovery results.

Methods:

This is a prospective, randomized, and comparative study. Our centre initiated LESSOP-DN in October 2010 and this trial were prospectively randomized for 56 consecutive living donors underwent LESSOP-DN (22 left DN and 4 right DN) and pure laparoscopic donor nephrectomy (PLDN) (23 left DN and 7 right DN) from December 2014 to July 2015. The primary endpoint of this study was cosmetic result from patient-reported questionnaire. We evaluated demographics, clinical outcomes, pain scores using visual analogue scale (VAS), and results of questionnaire, including the RAND 36-item short-form health survey (SF-36) and patient-reported overall convalescence.

Results:

There were no demographic differences between both groups, including donors and recipients. The median time to renal extraction (61 (45–105) vs. 66 (25–95) minutes; p=0.275), warm ischemia time (164.5 (103–337) vs. 157.5 (84–359) seconds; p=0.902), estimated blood loss (10 (5–240) vs. 10 (5–300) minutes; p=0.833), transfusion (0 vs. 1 case), length of hospital stay (3 (3–9) vs. 3 (3–13) days; p=0.336), and complication rate (15.4 vs. 20.0 %; p=0.737) were similar in both LESSOP-DN and PLDN groups. There was no conversion to open or hand-assisted surgery during study period. The postoperative pain scores using VAS and analgesic requirements converted to morphine-equivalent dosage (90.33 ± 38.94 vs. 94.23 ± 41.33 mg; p=0.718) were similar until discharge day after surgery. The LESSOP-DN group had a smaller incision length (4.5 (3.7–10.0) vs. 7.0 (4.5–10.0) cm; p<0.001) and higher cosmetic scores (16.2 ± 4.9 vs. 21.4 ± 3.0; p<0.001). Two graft losses in each group were occurred. Two recipients died from septic shock and pneumonia. The donor’s quality of life (SF-36), body image scores, and recovery data were comparable for both groups.

Conclusions:

Intraoperative and postoperative results show that LESSOP-DN group is comparable with PLDN group. LESSOP-DN group has better cosmetic results than PLDN group. LESSOP-DN might contribute comparable recovery and better cosmetic results to the altruistic donors.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S107.

MP-11.01: Validation of perioperative blood transfusion as a surgical quality indicator of radical cystectomy for urothelial bladder cancer

D Robert Siemens ¹, R Christopher Doiron ¹, Shelly Wei ¹, Chris Booth ¹

Abstract

Introduction and Objectives:

Perioperative blood transfusion (PBT) has been evaluated as a quality-of-care indicator in both oncologic and non-oncologic surgical cases. Previous single-centre studies of perioperative blood transfusion at the time of radical cystectomy (RC) have suggested a potential association with long-term cancer survival. Here, we describe factors associated with PBT at RC in routine clinical practice and evaluate its association on survival to explore its utility as a quality indicator of surgical care.

Methods:

Electronic records of treatment and surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients with bladder cancer who underwent RC and PBT between 2000 and 2008. Hospital discharge records were used to identify PBT. Modified Poisson regression model was used to determine the factors associated with PBT. A Cox proportional hazards regression model was used to explore the association between PBT and overall (OS) and cancer-specific (CSS) survival.

Results:

Among the 2593 patients with RC from 2000–2008, 62% received an allogenic red blood cell transfusion. The frequency of PBT decreased over the study period (from 68% in 2000 to 54% in 2008; p<0.001). Factors associated with receiving PBT included age (80+ years RR 1.25, 95% CI 1.14–1.39), sex (female RR 1.40, 95% CI 1.33–1.48), greater comorbidity (RR 1.11, 95% CI 1.03–1.20), T stage (T4 tumour RR 1.24, 95% CI 1.12–1.36), and surgeon volume (lowest quartile RR 1.18, 95% CI 1.08–1.28). Use of PBT was associated with inferior early outcomes including median length of stay (11 days vs. 9 days; p<0.001), 90-day readmission rate (38% vs. 29%; p<0.001) and 90-day mortality (11% vs. 4%; p<0.001). OS (32% vs. 47%; p<0.001) and CSS (38% vs. 54%; p<0.001) at five years were lower among patients with PBT. These differences in long-term survival persisted on multivariate analysis (OS HR 1.33, 95% CI 1.20–1.48; CSS HR 1.39, 95% CI 1.23–1.56). This observational study is limited by unmeasured confounding variables that could not be corrected for in our adjusted analyses.

Conclusions:

Although rates are decreasing, these data suggest very high utilization rate of PBT at time of RC in routine clinical practice. PBT is associated with substantially worse early outcomes and long-term survival. This association persists despite adjustment for disease-, patient- and provider-related factors, suggesting that PBT is an important and valid indicator of surgical care of bladder cancer.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S107.

MP-11.02: Impact of pathology review on clinical management of patients with bladder cancer in a contemporary era

Samer Traboulsi ¹, Fadi Brimo ², Yutong Yang ², Chelsea Maedler ², Simon Tanguay ¹, Armen-G Aprikian ¹, Wassim Kassouf ¹

Abstract

Introduction and Objectives:

Treatment decisions in bladder cancer depend heavily on the pathology report. The TNM and World Health Organization (WHO) classifications standardized the reporting of lesions, however, discrepancy between pathological reports and review is still considerable. We evaluated the implications of stage and grade discrepancy and other prognostic factors on the risk category in bladder cancer and its subsequent influence on treatment strategy.

Methods:

98 consecutive pathology specimens from transurethral resections in patients with suspected bladder tumours obtained from outside hospitals were reviewed at our institution by a genitourinary pathologist. Patients were classified into risk groups according to the pathology reports obtained before and after review. A management course was proposed according to the local institutional practices and main urological guidelines.

Results:

Overall, 33/98 (33.7%) of reviews had significant changes associated with management implications, mainly due to changes in risk category. On review, 12 patients were recommended radical cystectomy instead of conservative management, two radical cystectomies due to downstaging from T2 to T1. Six patients who remained T1after review were, however, advised for early cystectomy as a treatment option since they were reclassified from high-risk to very high-risk non-muscle invasive bladder cancer secondary to high-risk features, such as carcinoma in situ or lymphovascular invasion found on review. 10 patients initially staged as T2, were strongly advised for neoadjuvant chemotherapy before cystectomy after demonstrating lymphovascular invasion or high-risk variant histology on review.

Conclusions:

Review by a genitourinary pathologist remains important, as it defines more clearly the tumour risk category and influences the management of bladder cancer patients. A complete initial pathological report may potentially further decrease the discrepancy between initial and review reports.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S107.

MP-11.03: Effect of metformin on recurrence and progression in patients with non-muscle invasive bladder cancer

Samer Traboulsi ¹, Bassel G Bachir ¹, Faysal A Yafi ¹, Simon Tanguay ¹, Armen-G Aprikian ¹, Wassim Kassouf ¹

Abstract

Introduction and Objectives:

Non-muscle invasive bladder cancer (NMIBC) is characterized by high recurrence rates and significant progression rates. A large proportion of diabetics are treated with metformin, an effective antidiabetic with a good safety profile. Metformin is postulated to have antineoplastic activity due to its inhibitory activity on mammalian target of rapamycin (mTOR). We assessed the effects of metformin on bladder cancer recurrence and progression in patients with NMIBC.

Methods:

A retrospective analysis of patients with NMIBC was performed between 1975 and 2014. All benign histology and non-urothelial tumours were excluded from the analysis. Standard methodology, using univariate and multivariate analysis, was conducted on various clinicopathologic variables, as well as on the use of metformin.

Results:

Overall 1480 patients with a median age of 69.5 years were included. The use of metformin was not associated with recurrence-free survival. However, patients on metformin had a significantly decreased rate of grade progression on multivariate analysis (HR 0.37, CI 0.16–0.90; p=0.027). The use of metformin was significantly associated with stage progression on multivariate analysis (HR 0.4, CI 0.19–0.84; p=0.015).

Conclusions:

The use of metformin may have protective effects in patients with NMIBC. Prospective validation of these findings is warranted.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S108.

MP-11.04: Effect of piece and tumour size from resected renal parenchyma post-laparoscopic partial nephrectomy on renal function

Ernest Chan ¹, Shawna Boyle ², Patrick P Luke ³

Abstract

Introduction and Objectives:

There is interest in predicting loss of renal function post-partial nephrectomy (PN). The relative impact of piece and tumour size with regards to alteration in renal function post-PN is controversial.

Methods:

We performed a retrospective review of patients who underwent laparoscopic PN between October 2002 and May 2011. Only patients with complete data with regards to pre- and postoperative renograms, and tumour sizes from imaging and pathology reports were included (58/280). Using measurements from the resected specimen pathology reports, volumetric estimates for tumour size and piece size were generated based on ellipsoid and conoid formulas, respectively. Resected parenchyma (RP) was calculated by subtracting the tumour size from its corresponding piece size. Ipsilateral renal function (IRF) was calculated by multiplying the percentage of contribution from the MAG3 renogram by the total estimated glomerular filtration rate (eGFR). The effect of tumour size, piece size, and RP on IRF was assessed at three days and 6–12 weeks postoperatively.

Results:

Increasing tumour size and RP were determined to be significantly associated with decreased postoperative IRF at three days (p=0.002, R²=0.162; p=0.014, R²=0.096) and at 6–12 weeks postoperatively (p=0.008, R²=0.188; p=0.03, R²=0.116). Not surprisingly, piece size was associated with decreased postoperative IRF only if the tumour was endophytic (p=0.019; R²=0.701). Clamp time was not significantly associated with decreased postoperative IRF.

Conclusions:

Increasing RP and tumour size were associated with decreased IRF in patients undergoing laparoscopic PN. In endophytic tumours, piece size predicted IRF loss, which may have implications on surgical technique (enucleation, clamp time) when trying to minimize renal functional loss in these cases.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S108.

MP-11.05: Can early dynamic phase of 18 F-FDG PET/CT better predict grade and T-stage of urinary bladder cancer compared to post-diuretic phase imaging: A prospective study

Uttam Mete ¹, Abhishek Sharma ², Ashwani Sood ², Nandita Kakkar ³, BR Mittal ²

Abstract

Introduction and Objectives:

To find out the correlation of standardized uptake value (SUVmax) calculated during early dynamic and delayed post-diuretic phase of 18 F-FDG PET/CT studies with the grade and T-stage of urinary bladder cancer.

Methods:

39 patients with bladder carcinoma had undergone 18 F-FDG PET/CT. The SUVmax of the bladder tumours during early dynamic imaging of the pelvis (initial two minutes and at 10 minutes indicating perfusion phase), at the rate of two minutes/frame starting from the time of injection and at delayed imaging (60 minutes post-injection, indicating metabolic activity) were calculated. All patients had undergone surgery within the following three months. The SUVmax of both the phases were compared to the grade and T-stage of the tumours.

Results:

SUV max of the early dynamic imaging of various grades and stages was different from the SUVmax at 60 minutes. High-grade tumours showed a trend towards higher SUVmax both at two2 minutes (5.4 ± 1.4 vs. 4.7± 1.6; p=0.144) and at 10 minutes (8.7 ± 2.2 vs. 7.5 ± 2.7; p=0.160). This difference was statistically significant for stage T1 tumours (6.8 ± 0.8 vs. 5.5 ± 1.2; p=0.04). Non-invasive Ta tumours had significantly less SUVmax than higher-stage tumours during the early dynamic imaging at two minutes (SUVmax for Ta, T1, T2, T3, and T4 were 3.3 ± 2.6, 6.2 ± 1.2, 4.4 ± 1.0, 6.4 ± 1.3, and 5.9 ± 1.3, respectively). No such difference was noted in delayed imaging (SUVmax for Ta, T1, T2, T3, and T4 were 13 ± 4.6, 14.9 ± 6.8, 18.3± 15.5, 19.9 ± 3.6, and 10.3 ± 1.5, respectively).

Conclusions:

Statistically significant low SUVmax at early dynamic phase imaging was noted for low-grade tumours compared to high-grade lesions. This difference was not noted at standard imaging done at 60 minutes. Ta tumours had very low SUVmax compared to non-Ta tumours. Compared to delayed imaging, early dynamic imaging better predicts the T-stage, grade, and aggressiveness of the bladder tumours.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S108.

MP-11.06: Nutritional preoperative factors and risk of complications for subjects undergoing radical cystectomy: A systematic review

Janie Allaire ¹, Tal Ben-Zvi ², Benoit Lamarche ¹, Yves Fradet ^1,², Louis Lacombe ^1,², Vincent Fradet ^1,²

Abstract

Introduction and Objectives:

Radical cystectomy (RC) with urinary diversion is the standard surgical treatment of muscle invasive bladder cancer, but is associated with a high complications rate. Reports of RC complications have drawn much attention during recent years. While nutritional status influences the cancer patients’s ability to resist and respond to surgical stress, few nutritional factors have been identified to predict the risk of developing complications after RC. We conducted a systemic review to identify preoperative nutritional factors reported in the litterature and their effects on RC complications.

Methods:

We searched MEDLINE and EBSCO publications dating from January 2005 to November 2015. All English language cohort and case-control studies evaluating preoperative nutritional status and the risk of complications or mortality after RC in bladder cancer subjects were selected. Two reviewers performed the study selection. We used the Quality Assessment Tool for Quantitative Studies for the objective assessment of studies.

Results:

Low serum albumin values increases the risk of mortality. High body mass index appears to increase the risk of developing venous thromboembolism after RC in bladder cancer patients. No other significant predictor of complications has been identified.

Conclusions:

To date, only serum albumin values and body mass index have been isolated as nutritional factors impacting RC complications. A large heterogenity in study structure, results, and reporting methods was found in the urological litterature and hampers. Prospective studies, using standardized methods of defining and reporting complications, are required in order to identify modifiable nutritional preoperative risk factors of morbidity, mortality, and complications post-RC.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S108–S110.

MP-11.07: Impact of epidural analgesia for open radical cystectomy with ileal conduit on bowel function and length of stay: A retrospective study in 61 patients

Matthieu Gratton ¹, Frédérick D’aragon ², Guillaume Carrier ¹, Simon Ouellet ¹, Claudio Jeldres ¹, Robert Sabbagh ¹

Abstract

Introduction and Objectives:

To assess the effect of perioperative analgesia on postoperative outcomes in adult patients undergoing open radical cystectomy with ileal conduit.

Methods:

We retrospectively reviewed all cases of open radical cystectomy with ileal conduit for bladder cancer between 2011 and 2015 at our institution. Patients were divided into two groups: epidural analgesia (EA) and patient-controlled analgesia (PCA). Clinicopathologic data were available for all patients and four postoperative outcomes were compered between the groups, namely: time to normal transit (TNT), time to normal diet (TND), length of stay (LOS), and total systemic morphine consumption at seven days in postoperative equivalent (TSM). A subanalysis was performed to address the impact of high thoracic EA (HT) (T6–T10) vs. low thoracic and lumbar EA (LTL) (T11–L4) on the same outcomes. Statistics relied on Fisher test or Chi-square comparison between the group and uni- or multivariate analysis relied on logistic regression models.

Results:

A total of 61 patients were identified, 49 in the EA group and 12 in the PCA group. No differences were recorded for body mass index (BMI), American Society of Anesthesiologists (ASA) score, estimated blood loss, received perioperative fluid, operative time, pathologic staging and Clavien scores at 30 days. In univariate analysis, no statistically significant differences were recorded in the TNT (3.5 vs. 4.5 days; p=0.071), TND (6 vs. 6 days; p=0.435), LOS (10.0 vs. 12.5; p=0.270) and TSM (95.0 vs. 131.5; p=0.081) between both groups. However, a trend toward shorter TNT, TND, and LOS was observed in the EA group with a lower TSM. Sample size may have underpowered our analysis. A subanalysis of the impact of HT vs. LTL on the same four postoperative issues showed no differences.

Conclusions:

Type of analgesia was not associated with TNT, TND, LOS, or TSM. However, a favourable trend was recorded toward EA use regarding the studied outcomes. Sample size limitation may have resulted in underpowered analyses.

Table 1.

MP-11.07. Patient and tumour characteristics based on type of analgesia

Variables	PCA (n=12)	Epidural (n=49)	p value
Age, years (SD)	64.48 (11.6)	72.03 (12.6)	0.095
Male, n (%)	10 (83.3)	40 (81.6)	0.89
Charlson Comorbidity Index (SD)	5 (1.45)	6 (1.61)	0.002
BMI, kg/m² (SD)	27.6 (4.01)	28.51 (5.59)	0.337
EBL	600 (743.7)	600 (368.41)
Hb variation pre to postoperative	17.5 (15.08)	20 (12.68)
ASA, n (%)			0.96
1	0 (0)	1 (2)
2	7 (58.3)	27 (55.1)
3	5 (41.7)	21 (26.5)
Active smoking	10 (83.3)	44 (89.8)	0.532
24h perioperative fluids (SD)	6.33 (0.71)	6.05 (1.67)	0.92
Operative time	315 (26.2)	300 (37)	0.26
Pathologic stage (%)			0.84
pT0	(33.3)	22.4
pTa/pTis/pT1	(8.3)	24.5
pT2+	(58.3)	53.1
N+	(33.3)	24.5	0.66
Clavien Complication Scores at 30 days (%)
None	33.3	32.7	0.970
2 or less	41.7	42.8
3 and 4	25	24.5

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Table 2.

MP-11.07. Postoperative outcomes

Variables	PCA (n=12)	Epidural (n=49)	p value
Time to normal diet (SD)	6 (4.08)	6 (3.71)	0.435
Total morphine consumption (SD)	131.53 (159)	95.0 (76.15)	0.081
Time to transit (SD)	4.5 (2.59)	3.5 (2.48)	0.071
Length of stay (SD)	12.5 (8.46)	10 (9.8)	0.270

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References

1.Maffezzini M, Campodonico F, Canepa G, et al. Current perioperative management of radical cystectomy with intestinal urinary reconstruction for muscle-invasive bladder cancer and reduction of the incidence of postoperative ileus. Surgl Oncol. 2008;17:41–8. doi: 10.1016/j.suronc.2007.09.003. [DOI] [PubMed] [Google Scholar]
2.Mazul-Sunko B, Gilja I, Jelisavac M, et al. Thoracic epidural analgesia for radical cystectomy improves bowel function even in traditional perioperative care: A retrospective study in eighty-five patients. Acta Clin Croat. 2014;53:319–25. [PubMed] [Google Scholar]
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Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S110.

MP-11.08: Total penile glans resurfacing to maximize penile form and function in superficial penile cancer: MI-PECANS

Fardod O’Kelly ¹, Dara Lundon ¹, Peter Lonergan ¹, Paul Sweeney ², Ivor Cullen ³, Paul Hegarty ¹

Abstract

Introduction and Objectives:

The treatment of malignant penile lesions has traditionally been with radical surgery (2 cm margins). Radical surgery has demonstrated excellent local control rates, although associated with significant psychological morbidity and sexual dysfunction. Total glans resurfacing results in a good cosmetic appearance and maximum phallic length, with preservation of sexual and urinary function, without compromising oncological control. The objective of this study was to investigate the role of a minimally invasive approach to superficial penile cancer in preserving both function and appearance, and whether this led to inferior oncological control.

Methods:

A consecutive series referred for the treatment of penile malignancy were prospectively analyzed over 12 months. After clinical staging and grading, those patients offered glans-preserving surgery were analyzed for oncological and functional outcomes.

Results:

28 patients were referred with penile malignancies over a 24-month period, of which 17 (63%) underwent total glans resurfacing. The median (range) age of the patients at presentation was 54.8 years. There was complete graft take in 94.2% patients. There were no recurrences and only one patient required further surgical intervention. All patients stated that the sensation at the tip of their penis was either no different or better after surgery. 81% felt that their sex life had been improved. Overall patient satisfaction was high, all scoring 5 on the visual analogue scale.

Conclusions:

Careful tumour risk assessment and appropriate patient choice is necessary. The need for close observation is also essential, as the long-term recurrence rates for these techniques are still unknown. However, the advances in penile preserving surgery, in conjunction with other techniques, such as dynamic sentinel lymph node biopsy, has transformed the approach to management of penile cancer and reduced the physical and psychological morbidity associated with treatment.

References

1.Hegarty PK, Shabbir M, Hughes B, et al. Penile-preserving surgery and surgical strategies to maximize penile form and function in penile cancer: Recommendations from the United Kingdom experience. World J Urol. 2009;27:179–87. doi: 10.1007/s00345-008-0312-x. [DOI] [PubMed] [Google Scholar]
2.Pietrzak P, Corbishley C, Watkin N. Organ-sparing surgery for invasive penile cancer: Early followup data. BJU Int. 2004;9:1253–7. doi: 10.1111/j.1464-410X.2004.05153.x. [DOI] [PubMed] [Google Scholar]
3.Shabbir M, Muneer A, Kalsi J, et al. Glans resurfacing for the treatment of carcinoma in situ of the penis: Surgical technique and outcomes. Eur Urol. 2011;59:532–6. doi: 10.1016/j.eururo.2010.09.039. [DOI] [PubMed] [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S110.

MP-11.09: Uretero-ileal anastomotic strictures in patients undergoing cystectomy and urinary diversion for benign and malignant disease

Taylor E Remondini ¹, Kevin V Carlson ², Richard J Baverstock ²

Abstract

Introduction and Objectives:

Cystectomy with urinary diversion is performed for benign (neurogenic bladder, radiation cystitis, interstitial cystitis) or malignant (muscle-invasive bladder cancer) disease. Uretero-ileal anastomotic strictures are an uncommon, but challenging complication of this surgery. We herein review our stricture rates and our experience with their management.

Methods:

We retrospectively identified patients who underwent cystectomy by two urologists (RJB, KVC) in Calgary, Alberta, via an established database. Postoperative complications within hospital, within 90 days of the surgery and beyond 90 days were reviewed. Statistical analysis of nominal data was assessed using Pearson’s Chi-square test for association, where p<0.05 was considered significant.

Results:

Of 126 patients, 115 (91.3%) received ileal conduits while 11 (8.7%) received ileal neobladders. Of these patients, 14 (11.1%) had past exposure to pelvic radiation: two received brachytherapy for prostate cancer, while 12 received external beam radiotherapy (EBRT). Uretero-ileal anastomotic strictures were observed in 8.7% of patients. Interventions included nephrostomy with antegrade stenting (36.4%), endoscopic laser incision (27.3%), and surgical re-implantation (36.4%). Of patients that had past radiation exposure, 21.4% went on to have strictures, while 7.1% of those with no radiation history had strictures (p=0.074). Patients that had EBRT prior to surgery were more likely to develop uretero-ileal anastomotic strictures than patients that had no exposure (OR 4.42, 95% CI 0.99–19.62; p=0.036).

Conclusions:

We report an uretero-ileal anastomotic stricture rate of 8.7%. These patients may require multimodal management, including open surgical re-implantation. Our data confirms a relationship between pelvic EBRT exposure and stricture incidence.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S110–S111.

MP-11.10: How a single educational intervention can increase the referral for and usage of neoadjuvant chemotherapy in bladder cancer cases

Taylor E Remondini ¹, Kevin V Carlson ², Richard J Baverstock ²

Abstract

Introduction and Objectives:

Following a multidisciplinary round in May 2013, we advanced our efforts to ensure patients were provided the option of neoadjuvant chemotherapy (NAC) for its potential survival advantage in muscle-invasive bladder cancer (MIBC) cases. We, herein, review our use of NAC and experience with complications of its use and effect on early surgical outcomes.

Methods:

We retrospectively identified MIBC patients who received cystectomy by two urologists (RJB, KVC) in Calgary, Alberta. Referral rates to medical oncology, NAC use, reasons for refusal or denial of NAC, complications during its administration, pathological outcomes, and postoperative complications within 90 days of surgery were reviewed. Statistical analysis of nominal data was assessed using Pearson’s Chi-square test for association, where p<0.05 was considered significant.

Results:

Since May 2013, 30 of 35 patients (85.7%) were referred for NAC and 15 (42.9%) received it. Prior to this date, only eight of 56 (14.3%) had been referred and three (5.4%) received it. Of those patients with recorded reasons for not receiving NAC after referral, 17 patients were denied or declined NAC because of renal dysfunction (35.3%), patient concerns about side effects (17.6%), need for immediate surgery (17.6%), and patient perception of no benefit (11.8%). Of the 18 patients who received NAC, 83.3% received four full cycles. Eight NAC patients (44.4%) experienced 12 unique complications during treatment, including neutropenia (16.7%), thrombocytopenia (16.7%), electrolyte abnormalities (16.7%), hyperglycemia (11.1%), deep vein thrombosis (DVT) (11.1%), pulmonary embolism (PE) (11.1%), need for blood transfusions (5.6%), new onset atrial fibrillation (5.6%), ischemic bowel (5.6%), and reversible encephalopathy syndrome (5.6%). Positive lymph nodes were seen in 27.8% of NAC patients vs. 32.9% who did not receive it (p=0.68). No difference was seen in the surgical margin status between these groups: NAC (16.7%) vs. no NAC (17.8%) (p=0.909). There was no significant difference between groups in postoperative complications within 90 days, such as blood transfusion use (p=0.805), ileus (p=0.569), TPN use (p=0.957), sepsis (p=0.900), DVT (p=0.717), PE (p=0.982), myocardial infarction and stroke (p=0.245), wound dehiscence (p=0.515), wound infection (p=0.396), and stoma dehiscence or herniation (p=0.370).

Conclusions:

We, herein, demonstrate that a single, multidisciplinary educational intervention dramatically increased both referral for and usage of NAC for MIBC. However, our data suggest that these patients are put at risk of significant complications during NAC administration without apparent early oncologic benefit. Long-term followup will be required to determine if a survival advantage is realized.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S111.

MP-11.11: Complications, predictors and outcomes of percutaneous renal biopsies

Premal Patel ¹, Kamaljot S Kaler ², Deepak Pruthi ¹, Iain Kirkpatrick ³, Christie Rampersad ⁴, Dejana Radulovic ³, Thomas B McGregor ¹

Abstract

Introduction and Objectives:

There has been a renaissance of percutaneous renal biopsies (PRBs) in the management of patients with renal masses. Our study looks at our initial experience with PRBs and looks to define predictors of complications and outcomes.

Methods:

A prospective database of patients undergoing PRBs at St. Boniface General Hospital was developed in September 2013. Patient age, gender, tumour laterality and size, R.E.N.A.L. nephrometry score, biopsy complications, biopsy pathology results, and if applicable, final surgical pathology was extracted from patient charts. For our analysis, we included patients with masses less than 10 cm in size, as well as masses that were amendable to R.E.N.A.L. nephrometry scoring. From January 2012 to October 2015, 105 patients underwent percutaneous renal biopsies and 72 met our inclusion criteria.

Results:

Mean patient age was 66.1 (range 45–89) with 43 males and 29 females. 61 (85%) patients had no complications with the remaining complications being Clavien-Dindo Grade 1. Of the 72 biopsies, 43 (60%) were malignant, 19 (26%) were insufficient for diagnosis, and 10 (14%) were found to be benign. With regard to predictors of adequate tissue for a diagnostic biopsy, we found no association with age, gender, laterality, tumour size, skin-to-tumour distance, and R.E.N.A.L nephrometry score (subscore and total score analysis). Within our followup period, 25 patients underwent surgery. 22 (88%) of these patients had adequate tissue on initial biopsy for a diagnosis, which were all found to be congruent with final surgical pathology.

Conclusions:

PRBs are safe, as demonstrated by our centre’s minimal complication rate. Our study highlights the utility of a preoperative biopsy in patient management, as 11 (15%) of our cohort avoided unnecessary surgical intervention for a benign tumour.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S111–S112.

MP-11.12: Catamnestic followup of renal cell carcinomas among atomic bomb survivors according to radiation exposure status

Kenichiro Ikeda ¹, Jun Teishima ¹, Tetsutaro Hayashi ¹, Keisuke Goto ¹, Akio Matsubara ¹

Abstract

Introduction and Objectives:

More than 65 years have passed since exposure to the atomic bomb (A-bomb) in Hiroshima. There are many reports on radiation carcinogenesis in many carcinomas and several prospective cohort studies were conducted. So far, however, there have been few reports on the prognosis of A-bomb survivors vs. patients not exposed to A-bomb radiation (non-exposed). In this study, we evaluated differences in the prognosis of primary renal malignancies in A-bomb survivors and the non-exposed.

Methods:

Of 479 patients who underwent nephrectomy at our hospital from March 1991 to December 2011, with renal cell carcinoma diagnosed in the resected specimen, 255 patients with evaluable cases in the postoperative course and birth month before June1946, which included prenatal exposure to A-bomb radiation, were included. We retrospectively evaluated overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS) rates. Patient clinicopathological findings were also analyzed.

Results:

Of these 255 patients, 35 (13.7%) patients were A-bomb survivors. Mean age, sex, stage groupings, and histological classification and grade were similar between the A-bomb survivors and the non-exposed. Clinical T1 (cT1) patients were observed significantly more frequently among A-bomb survivors (32/35, 91.4%) than among the non-exposed (125/220, 56.8%; p<0.001). At a median followup of 47 months, OS rates at five and 10 years were 92.8% and 87.7%, respectively, in the A-bomb survivors and 74.6% and 69.3%, respectively, in the non-exposed (p=0.053). CSS rates at five and 10 years were 92.8% and 92.8%, respectively, in A-bomb survivors and 81.9% and 80.3%, respectively, in the non-exposed (p=0.137). DFS rates at five and 10 years were 92.7% and 92.7%, respectively, in A-bomb survivors and 86.7% and 83.7%, respectively, in the non-exposed (p=0.192). OS rates was also compared in cT1, there was no significant difference in A-bomb survivors and non-exposed (p=0.690). Multivariate analysis of prognosis showed that female and cT1 among A-bomb survivors were significantly different from non-exposed.

Conclusions:

Renal cell carcinoma in A-bomb survivors, cT1 is the time of diagnosis was significantly higher than non-exposed. However, OS was no difference between the two.

Table 2.

MP-11.12. Univariate and multivariate Cox regression analyses of clinicopathological factors for the prediction of cancer-specific survival in 248 RCC patients

Parameter		Univariate analysis		Multivariate analysis

		p value	HR	95% CI	p value
A-bomb exposure	Not exposed vs. exposed	0.072	0.821	0.209–2.718	0.755
Sex	Female vs. male	0.028	1.189	0.383–4.519	0.776
Age	≤71 vs. >71 years old	0.964
Symptoms	None vs. present	<0.001	1.510	0.596–4.234	0.395
Screening	None vs. present	0.008	2.179	0.344–42.60	0.449
Other overlapping cancer	None vs. present	0.005	0.552	0.113–1.992	0.383
Laterality	Right vs. left	0.312
Histological classification	CCRCC vs. NCCRCC	0.134
Histological grade	G1/2 vs. G3	0.001	1.92	0.756–4.504	0.162
Venous invasion	v0 vs. v1	<0.001	1.893	0.328–11.60	0.490
pT stage	pT1/2 vs. pT3/4	<0.001	6.718	1.265–44.37	0.023
pN stage	pN0 vs. pN1/2	<0.001	4.667	1.880–11.95	0.001
M stage	M0 vs. M1	<0.001	3.748	1.562–9.571	0.003

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CCRCC: clear-cell renal cell carcinoma; NCCRCC: non-clear-cell renal cell carcinoma.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S112.

MP-11.13: Accuracy of kidney cancer diagnosis and histological subtype within cancer registry data

Jeffrey G Himmelman ^1,^2,³, Jennifer Merrimen ^2,^3,⁴, Kara Thompson ^2,³, Chris Theriault ^2,³, Lori A Wood ^2,^3,⁵

Abstract

Introduction and Objectives:

Cancer registries are the mainstay for Canadian population-based cancer statistics. Each province captures this data in provincial registries, including the Nova Scotia Cancer Registry (NSCR).The goal of this study was to describe data from the NSCR about method of diagnosis and kidney cancer (KC) pathology and compare it to the actual pathology reports to determine the accuracy of diagnosis and histological subtype assignment.

Methods:

This retrospective analysis included patients with KC in the NSCR with an ICD-10-CM code C64.9 seen or treated in the largest provincial district from 2006–2010. From the NSCR, method of diagnosis and pathological diagnosis was recorded. From pathology reports, pathological diagnosis based on World Health Organization (WHO) classification was recorded.¹ All non-clear cell KC (non-ccKC) diagnosis from NSCR were compared to the actual pathology report for descriptive comparison and reasons for discordance.

Results:

723 patients make up the study cohort. 81.3% of patients were diagnosed on nephrectomy, 11.1% on radiography, 6.9 % biopsy, and 0.7% autopsy. By NSCR data, 52.8% had clear cell, 20.5% KC not otherwise specified (NOS), 12.7% papillary, 4% chromophobe, and many other non-ccKC. By pathology reports, 69.6% had clear cell, 15% papillary, 5% chromophobe, only 2.7% KC NOS. The large number of other non-ccKC will be presented. There was a discordance rate of 15.4% between NSCR data and diagnosis from pathology report.

Conclusions:

Registry data may not be accurate for the true incidence of KC, since 11.1% were based on radiology alone. Clear cell KC made up 52.8% of registry diagnosis, but 69.6% on pathology report review. Although papillary and chromophobe incidence did not vary a lot, other types of non-ccKC did. This registry data did not differentiate between papillary type I and II. Non-ccKC should not be considered one entity. One must be aware of the gaps in registry data for KC statistics.

References

1.Eble JN, Sauter G, Epstein JI, Sesterhenn IA. Pathology and genetics of tumours of the urinary system and male genital organs . IARC Press; 2004. [Google Scholar]

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S112.

MP-11.14: Factors affecting surgical wait times for renal masses

Simon Ouellet ¹, Robert Sabbagh ¹, Claudio Jeldres ¹

Abstract

Introduction and Objectives:

Surgical wait times (SWT) can result in distress for both the patient and the clinician. We assessed the factors predicting a longer SWT defined by the time from diagnosis of a renal mass to nephrectomy.

Methods:

We retrospectively reviewed all surgically managed cases of renal masses at our institution between 2006 and 2012. Patients were classified into two groups; SWT <3 and ≥3 months based on the median SWT for the whole cohort. We compared clinicopathologic data between the groups. A multivariate analysis was performed to determine the variables associated with SWT ≥3 months. Statistics relied on Student-t test, Chi-square, and multivariate analysis on logistic regression model. Significance level was set at 0.05.

Results:

A total of 350 patients were identified (180 with SWT <3 months and 170 with ≥3 months). No significant differences were recorded between the groups for age, gender, distance from hospital to home, body mass index (BMI), diabetes, hypertension, and smoking status. For SWT <3 months vs. ≥3 months, radiologic tumour size was 6.9 vs. 4.1 cm; p<0.01; T2-stage tumour or higher was 54 vs. 16%; p< 0.01; and use of laparoscopic partial nephrectomy was 12 vs. 51% ; p< 0.01). For SWT <3 months vs. ≥3 months, additional abdominal investigations after the initial diagnosis were performed with ultrasound (6 vs. 9%; p=0.42), computed tomography (CT) scan (65 vs. 81%; p=0.01), magnetic resonance imaging (MRI) (5 vs. 13%; p=0.01]), positron emission tomography (PET) scan (3 vs. 4%; p=0.78), and renal biopsy (2 vs. 8%; p=0.01). In multivariate analysis, factors associated with having a SWT ≥3 months were presence of diabetes (OR 2.9 (1.1–7.9)), smaller tumour size (OR 10.5 (10.3–10.7)), the use of additional investigations with MRI (OR 6.6 (1.4–33.3)), or renal biopsy (OR 11.0 (1.3–100.0)).

Conclusions:

Tumour size is the most important factor influencing the SWT; smaller tumours resulted in longer SWT. Other factors associated with having a SWT ≥3 months were presence of diabetes, and the use of additional investigation with MRI or renal biopsy.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S113.

MP-11.15: Epidural use in cystectomy is not associated with improved short- or long-term outcomes in routine clinical practice

R Christopher Doiron ¹, Christopher M Booth ^2,^3,⁴, Melanie Jaeger ⁵, Xuejiao Wei ⁴, D Robert Siemens ^1,^2,⁴

Abstract

Introduction and Objectives:

Use of perioperative thoracic epidural is a core component of surgical care pathways in cystectomy and ERAS protocols. Furthermore, there is evidence that use of neuraxial analgesia attenuates cancer recurrence in patients undergoing surgical resection of their malignancy. In this contemporary, population-based study, we report epidural use in patients undergoing cystectomy in routine clinical practice. We evaluate factors associated with use of regional anesthesia and the effect on short- and long-term outcomes.

Methods:

All patients undergoing cystectomy in the province of Ontario between 2000 and 2008 were identified using the Ontario Cancer Registry (OCR) and were linked to treatment and pathology records. OHIP billing codes were used to identify all patients who received a perioperative epidural. Multivariate logistic regression analysis was used to describe factors associated with epidural use, while a Cox proportional hazards model describes associations with survival.

Results:

Over the eight-year study period, 1628 patients underwent cystectomy — 54% (n=887) received an epidural, while 46% (n=741) did not. Higher surgeon, anesthesiologist, and hospital volume were all associated with increased epidural use (p<0.001). There was no difference between the groups in lengeth of stay, 30- and 90-day readmission rates, or 30- and 90-day mortality. In multivariate Cox proportional hazards analysis, epidural was not associated with improved five-year cancer-specific survival (HR 1.02, 95% CI 0.87–1.19; p=0.804) or five-year overall survival (HR 0.91, 95% CI 0.80–1.03; p=0.136)).

Conclusions:

Only 54% of cystectomy patients received an epidural in routine clinical practice. Those treated at higher-volume centres were more likely to receive an epidural. There was no difference in short- or long-term outcomes between the groups.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S113.

MP-11.16: Diabetes and kidney cancer outcomes: A propensity score analysis

Madhur Nayan ¹, Antonio Finelli ¹, David N Juurlink ², Peter C Austin ³, Girish S Kulkarni ¹, Robert J Hamilton ¹

Abstract

Introduction and Objectives:

Pre-existing diabetes has been associated with poor outcomes in various malignancies. However, there have been conflicting findings regarding the association between diabetes and outcomes in renal cell carcinoma.

Methods:

We performed a retrospective review of 893 patients undergoing nephrectomy for unilateral, M0, renal cell carcinoma between 2000 and 2014 at a tertiary academic centre. Inverse probability of treatment weights (IPTW) were derived from a propensity score model based on various clinical, surgical, and pathological characteristics. We used Cox proportional hazard models to evaluate the association between diabetes and disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS) in the sample weighted by the IPTW. Furthermore, to evaluate whether severity of diabetes was associated with survival outcomes, we performed separate analyses where IPTW were computed based on the probability of having diabetes that was controlled by medication.

Results:

Of the 893 patients, 158 (18%) had diabetes. Of these, 122 (77%) patients required medications for diabetes control while the remaining 36 (23%) had diet-controlled diabetes. Median followup was 47 months (interquartile range (IQR) 21–80). Diabetes at the time of surgery was not significantly associated with DFS (HR 1.12, 95% CI 0.62–2.00), CSS (HR 0.63, 95% CI 0.27–1.50), or OS (HR 1.23, 95% CI 0.79–1.91). We found similar results when we compared diabetics controlled with medication vs. non-diabetics or diet-controlled diabetics.

Conclusions:

We found no significant association between diabetes and survival outcomes in patients undergoing nephrectomy for M0 renal cell carcinoma.

Can Urol Assoc J. 2016 May-Jun;10(5-6Suppl1):S113.

MP-11.17: Assessing an intravesical administered second-generation antisense oligonucleotide targeting Heat Shock Protein 27 in bladder: A phase 1 clinical trial

Alan I So ¹, Sebastian Frees ¹, Eliana Beraldi ¹, Ladan Fazli ¹, Kim Chi ¹, Peter C Black ¹, Martin E Gleave ¹

Abstract

Introduction and Objectives:

Treatment options for patients with non-muscle invasive bladder cancer (NMIBC) are limited. Heat Shock Protein 27 (Hsp27) is a cytoprotective protein that has been linked to therapeutic resistance and disease progression in many malignancies, including bladder cancer (BCa). OGX-427, a second generation (2′-MOE) antisense oligonucleotide has been shown to inhibit Hsp27 expression in vitro and in vivo. A phase 1 clinical study was performed to assess the safety and pharmacodynamic (Pd) and biologic effects of intravesical treatments of OGX-427 using a presurgical dose-escalating design for patients with BCa.

Methods:

Eligible patients include patients with Ta, T1, or CIS and candidates for transurethral resection of the bladder tumour (TURBT), or patients with muscle invasive BCa and candidates for radical cystectomy (RC). Patients were treated with intravesical OGX-427 on Days 1, 3, 5, and 8 and then underwent surgery on Day 9–12. Dose was escalated after tolerability and safety assessment for each cohort from 20 to 750 uM. Dose-limiting toxicities (DLT) and adverse events (AE) were assessed. Pd properties of OGX-427 were determined through assessment of knockdown of Hsp27 by IHC. Anti-tumour activity was measured by response after OGX-427 by a secondary surgery compared to baseline histology.

Results:

24 patients were enrolled. 23 patients with NMIBC and one had cT2 disease treated by TURBT and RC, respectively. OGX-427 decreased expression of Hsp27 in tumours after treatment. Pathological staging of surgical specimens revealed that eight patients had initial complete responses. The remaining NMIBC patients had pTa tumours that ranged from G1-G2; the sole patient undergoing RC had pT2aG3 BCa. No significant drug-related AE were reported; no DLTs were observed.

Conclusions:

OGX-427 was well-tolerated intravesically with minimal toxicity. Our results indicate early evidence for activity of OGX-427 treatment in NIMBC that requires confirmation in phase 2/3 studies.

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PERMALINK

Podium Session 1: Prostate Cancer June 26, 2016 1050–1150

POD-01.01: Efficacy and safety of enzalutamide versus bicalutamide in younger and older patients with metastatic castration-resistant prostate cancer in the TERRAIN trial

D Robert Siemens

H Laurence Klotz

Axel Heidenreich

Simon Chowdhury

Arnauld Villers

Benoit Baron

Steve van Os

Nahla Hasabou

Fong Wang

David Forer

Neal D Shore

Abstract

Introduction and Objectives:

Methods:

Results:

Conclusions:

POD-01.02: A pan-Canadian contemporary analysis of active surveillance uptake for low-risk, localized prostate cancer in Canada

Narhari Timilshina

Veronique Ouellet

Shabbir M Alibhai

Anne-Marie Mes-Masson

Nathalie Delvoye

Darrel E Drachenberg

Antonio Finelli

Marie-Paule Jammal

Pierre Karakiewicz

Hélène Lapointe

Jean-Baptiste Lattouf

Kenny Lynch

Jean Benoit Paradis

Paula Sitarik

Alan I So

Fred Saad

Abstract

Introduction and Objectives:

Methods:

Results:

Conclusions:

Fig. 1.

POD-01.03: The burden of symptomatic skeletal events in castrate-resistant prostate cancer patients with bone metastases at three Canadian uro-oncology centres

Fred Saad

Neil E Fleshner

Alan I So

Jacques Le Lorier

Louise Perrault

Melanie Poulin-Costello

Raina Rogoza

Ewan JD Robson

Abstract

Introduction and Objectives:

Methods:

Results:

Conclusions:

Table 1.

POD-01.04: Prospective comparison of open vs. robot-assisted radical prostatectomy for clinically localized prostate cancer: Results from the University of Alberta radical prostatectomy database

Adrian S Fairey

Niels-Erik Jacobsen

Sunita Ghosh

Derek Bochinski

Michael Chetner

Lucas Dean

Howard Evans

Michael Hobart

David Mador

Blair St Martin

Keith F Rourke

Eric Estey

Abstract

Introduction and Objectives:

Methods:

Results:

Conclusions:

POD-01.05: Cardiovascular and skeletal-related complications among patients treated with surgery or radiotherapy for clinically localized prostate cancer: A population-based cohort study

Christopher JD Wallis

Alyson L Mahar

Raj Satkunasivam

Sender Herschorn