Objective: To evaluate the long-term functional and oncologic outcomes after robotic partial nephrectomy (RAPN) and radical nephrectomy (RARN).Materials and Methods: A retrospective review was performed on 1816 patients who underwent RAPN and RARN at our institution between January 2006 and January 2018. Patients with long-term follow-ups of at least 5 years were selected. Exclusion criteria included patients with a previous history of partial or radical nephrectomy, known genetic mutations, and whose procedures were performed for benign indications. Statistical analysis was performed with results as presented.Results: A total of 769 and 142 patients who underwent RAPN and RARN, respectively, met our inclusion criteria. The duration of follow-up was similar after the two procedures with a median of similar to 100 months. The 5- and 10-year chronic kidney disease (CKD) upstaging-free survivals were 74.5% and 65.9% after RAPN and 53% and 46.4% after RARN, respectively. Older age was identified as a potential predictor for CKD progression after RARN, whereas older age, higher body mass index, baseline renal function, and ischemia time were shown to predict CKD progression after RAPN. Renal cell carcinoma-related mortality rates for RAPN and RARN were equally 1.1%. No statistically significant differences were identified in the local recurrence, metastatic, and disease-specific survival between the two procedures.Conclusion: Compared with RARN, RAPN conferred a better CKD progression-free survival. Several factors were identified as potential predictors for clinically significant CKD progression both in the early and late postoperative phase. Long-term oncologic outcomes between the two procedures remained similarly favorable.

OBJECTIVES:To present a comprehensive report regarding our experience with single-port robotic surgery in our first 100 consecutive patients. We describe the diversity of procedures that can be performed with this platform as well as the challenges and complications we had with the application of this novel technology. METHODS:Between September 2018 and August 2019, data on 100 patients who underwent single-port robotic surgery were consecutively collected. Preoperative, intraoperative and early postoperative outcomes after various urologic procedures were recorded and analyzed. RESULTS:During the study period, 100 patients (age [range] 35-84 years; 88 [88%] Male) underwent various single-port robotic surgeries for different indications (Retroperitoneal [n = 14], Pelvic surgeries [n = 86]). Transperitoneal (n = 37), extraperitoneal (n = 53) and transvesical (n = 10) approaches have been used to access the target organs. Of these procedures, 73 (73%) were for different oncological indications: Radical prostatectomy (n = 60), Partial nephrectomy (n = 6), Retroperitoneal lymph node dissection (n = 1) and Radical cystectomy with intracorporeal diversion (n = 6). Surgery was successfully completed in all but 1 patient, in whom the surgery was converted to open surgery due to dense adhesions and failure to progress. Grades II-III postoperative complications were detected in (n = 9) patients. CONCLUSION:The purpose-built single-port robotic platform can be safely incorporated into the minimally invasive armamentarium. A wide range of pelvic and retroperitoneal urological procedures can be done with different approaches using this platform. Randomized trials with adequate sample size and postoperative follow up period is advisable for further evaluation of the outcomes and to determine the added value of this emerging technology.

OBJECTIVE To present our initial experience with single-port percutaneous transvesical simple prostatectomy using the novel SP robotic surgical system. METHODS Ten patients underwent single-port transvesical simple prostatectomy between February and November 2019. Percutaneous access to the bladder dome was made and all SP instruments were inserted through the SP multichannel cannula directly into the bladder. Prostate adenoma enucleation, hemostasis and trigonization were done according to the principles of open simple prostatectomy technique. Demographics and perioperative outcomes were prospectively collected and analyzed. RESULTS All procedures were performed successfully without the need for conversion to open surgery. Median preoperative estimated prostate size was 159 (Interquartile range (IQR) 108-223) grams. No intraoperative complications occurred. Median operative time and estimated blood loss were 190 (IQR 146-203) minutes and 100 (IQR 68-175) ml, respectively. Mean postoperative specimen weight was 84.3 +/- 34 grams. Median length of hospital stay was 19 (IQR 17-28) hours. All patients were satisfied with their urinary flow after catheter removal without any episode of acute urinary retention 1-6 months, postoperatively. CONCLUSION Single-port transvesical simple prostatectomy can be offered as an alternative treatment option for surgical management of lower urinary tract symptoms associated with large prostate adenoma. Sparing the peritoneal cavity, minimum dissection of the bladder, excellent visualization of the prostate fossa can be some of the potential advantages of this minimally invasive approach. Comparative studies with standard techniques are advisable to evaluate the surgical outcome and postoperative morbidity of each treatment modality. (C) 2020 Elsevier Inc.

OBJECTIVE:To identify preoperative factors that predict positive surgical margins in partial nephrectomy. MATERIAL AND METHODS:Using our institutional partial nephrectomy database, we investigated the patients who underwent partial nephrectomy for malignant tumors between January 2011 and December 2015. Patient, tumor, surgeon characteristics were compared by surgical margin status. Multivariable logistic regression was used to identify independent predictors of positive surgical margins. RESULTS:A total of 1025 cases were available for analysis, of which 65 and 960 had positive and negative surgical margins, respectively. On univariate analysis, positive margins were associated with older age (64.3 vs. 59.6, p<0.01), history of prior ipsilateral kidney surgery (13.8% vs. 5.6%, p<0.01), lower preoperative eGFR (74.7 mL/min/1.73 m2 vs. 81.2 mL/min/1.73 m2, p=0.01), high tumor complexity (31.8% vs. 19.0%, p=0.03), hilar tumor location (23.1% vs. 12.5%, p=0.01), and lower surgeon volume (p<0.01). Robotic versus open approach was not associated with the risk of positive margins (p=0.79). On multivariable analysis, lower preoperative eGFR, p=0.01), hilar tumor location (p=0.01), and lower surgeon volume (p<0.01) were found to be independent predictors of positive margins. CONCLUSION:In our large institutional series of partial nephrectomy cases, patient, tumor, and surgeon factors influence the risk of positive margins. Of these, surgeon volume is the single most important predictor of surgical margin status, indicating that optimal oncological outcomes are best achieved by high-volume surgeons.

89 Background: Prior work has questioned the safety of active surveillance (AS) for African-American (AA) men with prostate cancer. However, studies of AA men on AS are rare, and some show contradictory results as more AA men may undergo definitive therapy leaving a well-selected AS population. To overcome these limitations we performed a retrospective matched cohort study of AA men on AS. Methods: We queried our AS database (2000-2016) for all AA patients. AA men were matched to non-AA men using a 1:1 algorithm based on National Comprehensive Cancer Network (NCCN) risk, age at diagnosis, and year of diagnosis. Cohorts were compared on outcomes of NCCN risk reclassification, receipt of treatment, post-treatment recurrence, development of metastases, and prostate cancer specific mortality. Results: Fifty-nine AA patients were identified and matched, including 18 very low risk (31%), 24 low risk (41%), and 17 intermediate risk patients (29%). Groups were equally matched by NCCN risk and year of diagnosis, and had similar ages at diagnosis (65.6 years AA, 65.9 years non-AA, p=0.97). Initial PSA values were similar between groups (5.2 AA versus 5.1 non-AA, p=0.77). Rates of risk reclassification during AS were higher among AA patients (54% versus 39% p=0.09), though treatment (46% vs 44%) and post-treatment recurrence (11% vs 19%) rates were similar. While AA patients were more often reclassified, many were due to PSA rise (40% AA, 8% non-AA upgraded by PSA alone) rather than pathologic upgrading. AA patients had a longer time to reclassification and treatment than non-AA patients (2.9 and 2.8 years vs 0.9 and 1.0 years, p=0.14). Similar follow-up time was noted (AA 6.0 years versus non-AA 6.4 years, p=0.91). One patient in each group developed metastases. No cancer specific mortalities occurred. Conclusions: In a matched analysis of AA versus non-AA patients on AS, rates of risk reclassification were higher among AA patients, though receipt of treatment and treatment outcomes were similar between groups. Metastatic progression and prostate cancer mortality were rare in both groups. AS appears to be a reasonable option for AA patients with long treatment free periods and reasonable post-treatment outcomes.

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology I (MP01)1 Apr 2019MP01-11 LONG-TERM REOPERATION RATES FOLLOWING SURGERY FOR BPH: VARIATION BASED ON SURGICAL MODALITY Abhinav Khanna*, Navin Sabharwal, Khaled Fareed, James Ulchaker, Kyle Ericson, and Bradley Gill Abhinav Khanna*Abhinav Khanna* More articles by this author , Navin SabharwalNavin Sabharwal More articles by this author , Khaled FareedKhaled Fareed More articles by this author , James UlchakerJames Ulchaker More articles by this author , Kyle EricsonKyle Ericson More articles by this author , and Bradley GillBradley Gill More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000554875.83510.d8AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Surgeries for benign prostatic hyperplasia (BPH) are commonly performed by urologists worldwide. Durability of these surgeries is reflected by the need for repeat endoscopic surgery. While clinical trials offer insight into short and intermediate-term reoperation in a controlled setting, long-term retreatment rates in the real world are not well characterized. This study compared reoperation rates following various surgical modalities for BPH treatment. METHODS: A retrospective single health system database was used to identify patients undergoing a first-time surgery for BPH, including transurethral resection of the prostate (TURP), laser vaporization of the prostate (LVP), and simple prostatectomy (SP). The primary outcome was endoscopic reoperation at least 90 days after the index surgery. RESULTS: A total 4,985 patients underwent BPH surgery between 2001-2016, including 2,304 (46.2%) TURP, 2,549 (51.1%) LVP, and 132 (2.7%) SP. Median follow-up was 26.5 (IQR 7.1-59.0) months. Overall, 419 (8.4%) patients required a subsequent endoscopic operation, occurring a median 19.5 (IQR 7.7-39.3) months after initial BPH surgery. Significant differences in reoperation rates existed across surgical modalities, with the highest reoperation rate after LVP (268/2549, 10.5%), followed by TURP (148/2304, 6.4%), and lowest rate of subsequent endoscopic surgery after SP (3/132, 2.3%) (p<0.0001). On Cox proportional hazards regression analysis adjusting for baseline demographic and clinical characteristics, primary BPH surgical modality was independently associated with subsequent endoscopic surgery (p=0.007). Compared to LVP (referent), TURP (hazard ratio [HR] 0.78, 95% confidence interval 0.64-0.95) and SP (HR 0.28, 0.09-0.87) were less likely to require secondary surgery (Figure 1). CONCLUSIONS: Variation exists in rates of subsequent endoscopic surgery following surgical treatment of BPH, suggesting specific approaches provide differing long-term durability. Reoperations reflect increased patient morbidity and greater healthcare resource utilization. Discrepant reoperation rates should be factored into the shared decision-making process for BPH management. Source of Funding: None Cleveland, OH© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e5-e5 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Abhinav Khanna* More articles by this author Navin Sabharwal More articles by this author Khaled Fareed More articles by this author James Ulchaker More articles by this author Kyle Ericson More articles by this author Bradley Gill More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy V (MP66)1 Apr 2019MP66-01 APICAL INVOLVEMENT IS ASSOCIATED WITH ADVERSE PATHOLOGICAL OUTCOMES IN MEN WITH LOW RISK PROSTATE CANCER ELIGIBLE FOR ACTIVE SURVEILLANCE Ahmed Elshafei*, Khaled Fareed, Ayman S. Mousa, Beni Suef, Scott Lundy, Molly E DeWitt-Foy, Lewis Thomas, Ahmed Khalifa, Shih-Chieh Chueh, Amr Fergany, Andrew Stephenson, and Eric Klein Ahmed Elshafei*Ahmed Elshafei* More articles by this author , Khaled FareedKhaled Fareed More articles by this author , Ayman S. MousaAyman S. Mousa More articles by this author , Beni SuefBeni Suef More articles by this author , Scott LundyScott Lundy More articles by this author , Molly E DeWitt-FoyMolly E DeWitt-Foy More articles by this author , Lewis ThomasLewis Thomas More articles by this author , Ahmed KhalifaAhmed Khalifa More articles by this author , Shih-Chieh ChuehShih-Chieh Chueh More articles by this author , Amr FerganyAmr Fergany More articles by this author , Andrew StephensonAndrew Stephenson More articles by this author , and Eric KleinEric Klein More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000556933.26225.c9AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: To assess the association between the presence of apical lesion at time of prostate biopsy (PBx) and pathological outcomes after radical prostatectomy (RP) in men with favorable risk prostate cancer (PCa) eligible for active surveillance (AS). METHODS: We reviewed 525 patients who met NCCN very low risk (VLR) (n=339) and low risk (LR) (n=186) PCa definitions who underwent RP. In each risk category we assessed different potential predictors of adverse pathological outcomes at RP including demographics and clinical factors. We also assessed PBx specific factors including anatomical location of positive cores. Adverse pathological outcomes were defined as Gleason sum upgrading (GS 7 or greater), extra-prostatic extension, positive surgical margins, and/or seminal vesicle invasion. Univariate and logistic regression analyses were conducted in each risk category. RESULTS: Men with worse pathological outcome at RP in NCCN VLR category were older (P= 0.04),had higher median iPSA (P= 0.002), higher maximum cancer percentage/core (P= 0.001), higher percent of positive cores (P= 0.04) and higher percentage of apical cancer location at time of diagnostic biopsy (P= 0.01). Apical cancer location at PBx (OR 1.9, P= 0.01), age (OR. 1.05, P= 0.02), PSA (OR. 1.2, P= 0.02) and maximum cancer percentage /core (OR. 1.3, P= 0.0001) were independent predictors of adverse pathology outcomes (table 1). In NCCN LR men with adverse pathological outcomes at RP had higher disease burden in the form of higher median number of positive cores (P= 0.01), higher percent of positive cores (P=0.009), higher maximum cancer percentage/core (P= 0.001). In both unadjusted (P= 0.01) and logistic regression (OR. 3, P= 0.04) models, apical cancer location at PBx was associated with adverse pathological outcomes at time of RP. (Table 2) CONCLUSIONS: The presence of apical lesion on prostate biopsy in men with NCCN VLR/LR PCa increases the likelihood of adverse pathological outcomes on RP for those who go on to surgical treatment. Apical lesions are often under-sampled at time of prostate biopsy and may harbor unfavorable pathology. Men with apical lesion who elected AS may require additional apical sampling or mpMRI at time of confirmatory biopsy. Source of Funding: none Cleveland, OH; Egypt; Cleveland, OH© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e957-e958 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Elshafei* More articles by this author Khaled Fareed More articles by this author Ayman S. Mousa More articles by this author Beni Suef More articles by this author Scott Lundy More articles by this author Molly E DeWitt-Foy More articles by this author Lewis Thomas More articles by this author Ahmed Khalifa More articles by this author Shih-Chieh Chueh More articles by this author Amr Fergany More articles by this author Andrew Stephenson More articles by this author Eric Klein More articles by this author Expand All Advertisement PDF downloadLoading ...

Introduction: We aimed to compare perioperative, functional and oncological outcomes between robot-assisted partial nephrectomy (RAPN) and open partial nephrectomy (OPN) for highly complex renal tumors (R.E.N.A.L. nephrometry Score > 9). Methods: A retrospective review of 1,497 patients who consecutively underwent partial nephrectomy at a single academic tertiary center between 2008 and 2016 was performed to get data about patients who underwent RAPN and OPN for renal masses with RENAL score > 9. Baseline, perioperative, functional, and oncological outcomes were compared. Results: Two hundred and three RAPN and 76 OPN were extracted. Patients' demographics and tumors' characteristics were comparable between the groups. Blood loss (200 vs. 300 cc, P < 0.0001), intraoperative transfusion rates (3% vs. 15.8%, P < 0.001), and length of stay (3 vs. 5 days, P < 0.01) were lower for RAPN. A significant decrease in estimated glomerular filtration rate was observed from preoperative to postoperative period, regardless the approach (OPN, P = 0.026 vs. RAPN, P = 0.014). Conversion to radical nephrectomy was 7.8% and 5.9% for OPN and RAPN, respectively. At multivariable regression, open approach was predictive of intraoperative transfusion and reoperation. Overall actuarial rate of recurrence or metastasis was 4.3%, with 3 cancer-related deaths occurring after a median follow-up of 25 months. No differences were found between the groups. Conclusion: In our large single-institutional series of patients who underwent partial nephrectomy for highly complex renal tumors, robotic approach appeared to be a valuable alternative to OPN, with the advantages of reduced blood loss, ischemia time, transfusions rate, and length of stay. (C) 2018 Elsevier Inc. All rights reserved.

Background: Robot-assisted partial nephrectomy (RAPN) is an established, minimally invasive nephron-sparing technique with excellent perioperative and intermediate oncological outcomes. However, long-term oncological outcomes have not been reported to date. Objective: To report oncological and functional outcomes of RAPN among patients with minimum follow-up of 5 yr. Design, setting, and participants: Data for consecutive patients undergoing RAPN since October 2006 were extracted from a prospectively-maintained institutional PN database. Patients with benign tumors, genetic mutations, prior radical or ipsilateral PN, and those with follow-up of <5 yr were excluded. Intervention: Transperitoneal RAPN for renal cell carcinoma (RCC). Outcome measurements and statistical analysis: Demographic, perioperative, postoperative, functional, and oncological data were evaluated. A linear random-effects model was used to estimate the effect of follow-up duration on the estimated glomerular filtration rate (eGFR) after adjustment for potential confounders. Univariable competing-risks regression analyses were performed to evaluate the hazard ratio (HR) for cancer-related events for the variables of interest. Results and limitations: A total of 278 RAPNs for RCC were included. eGFR was significantly lower at follow-up time points than at baseline. At last follow-up (median 46 mo, interquartile range 30-58) the mean eGFR difference was -10.6 ml/min (95% confidence interval -12.56 to -8.66; p < 0.0001). There were 28 deaths (10.1%) in the cohort during the follow-up period, of which five (1.8%) were related to metastatic RCC. The 5-yr and 7-yr cumulative incidence of RCC deaths was 1.80% at both 5 and 7 yr, while the cumulative incidence of local recurrence was 3.61% and 4.16%, and that of metastasis was 3.24% and 4.57% at 5 and 7 yr, respectively. Univariable competing-risks regression revealed that higher Fuhrman grade (HR 8.76; p = 0.051), larger tumor size (HR 1.67; p < 0.0001), and tumor necrosis (HR 16.73; p = 0.0019) were independent predictors of RCC death. The retrospective design and potential selection bias due to patient selection in the early RAPN experience may limit the generalizability of the findings. Conclusions: This is the first study reporting minimum oncological follow-up of 5 yr after RAPN. The results demonstrate excellent long-term oncological outcomes after RAPN in a selected cohort of patients. Our data confirm that the renal functional deterioration after RAPN remains stable over time after the early postoperative decrease. Patient summary: Robot-assisted partial nephrectomy is being more widely used as a standard treatment for small localized renal cell carcinomas. This study reveals excellent long-term cancer control for both local recurrences and distant metastases. Renal function is stable after an initial postoperative deterioration. (C) 2018 Published by Elsevier B.V. on behalf of European Association of Urology.

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance III1 Apr 2018PD20-11 17-GENE GENOMIC PROSTATE SCORE CAN ACCURATELY DETERMINE THE NEED FOR CONFIRMATORY BIOPSY IN PATIENTS ELECTING ACTIVE SURVEILLANCE Daniel Hettel, Anna Faris, Shree Agrawal, Bryan Naelitz, Khaled Fareed, James Ulchaker, Andrew Stephenson, Michael Gong, and Eric Klein Daniel HettelDaniel Hettel More articles by this author , Anna FarisAnna Faris More articles by this author , Shree AgrawalShree Agrawal More articles by this author , Bryan NaelitzBryan Naelitz More articles by this author , Khaled FareedKhaled Fareed More articles by this author , James UlchakerJames Ulchaker More articles by this author , Andrew StephensonAndrew Stephenson More articles by this author , Michael GongMichael Gong More articles by this author , and Eric KleinEric Klein More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1015AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Men selecting active surveillance (AS) are often recommended to undergo a confirmatory biopsy to rule out the presence of adverse histological features that usually trigger immediate treatment. We sought to characterize the parameters of a 17-gene assay, the Genomic Prostate Score (GPS), to determine which patients benefit from a confirmatory biopsy with respect to upgrading or NCCN risk reclassification. METHODS All patients obtaining a GPS at a large tertiary referral center were identified utilizing a large, prospectively maintained GPS database. Biopsy data was manually retrieved from the electronic record. A confirmatory biopsy was defined as the first biopsy obtained within 12 months after the diagnostic biopsy. Grade reclassification was defined as any increase in grade group (GG) on confirmatory biopsy, and NCCN reclassification was defined as any increase in risk strata on confirmatory biopsy. Statistical methods include descriptive statistics and Wilcoxon Rank Sums. All analyses were performed utilizing JMP Pro 13 (SAS Institute). RESULTS 509 patients with a GPS were identified, of which 76 (15%) had a confirmatory biopsy. Median GPS (19 [15, 27] vs 23 [16, 28]; p=0.24) and likelihood of favorable pathology at prostatectomy (LFP) (80 [74, 84] vs 81 [76, 85]; p=0.31) were not significantly different between patients obtaining a confirmatory biopsy and those that did not. Of those patients obtaining a confirmatory biopsy, 26 (34%), 41 (54%), and 9 (12%) were very low risk (VLR), low risk (LR), and intermediate risk (IR) at diagnosis, respectively. GG distribution was similar, with 67 (88%) and 9 (12%) patients diagnosed as GG 1 and 2. GG reclassification was observed in 19 (25%) patients, and NCCN reclassification was observed in 20 (26%) patients. No significant difference was observed in the median GPS (18 [15, 26] vs 20 [15, 28], p=0.74) or LFP (79 [75, 81] vs 80 [74, 84], p=0.62) of those experiencing grade reclassification, or of those experiencing NCCN reclassification (GPS: 18 [15, 26] vs 19 [14, 28], p=0.68; LFP: 79 [75, 83] vs 80 [73, 84], p=0.82). A GPS ≤12 reliably identified patients unlikely to experience grade reclassification (sensitivity = 0.89, specificity = 0.82) or NCCN reclassification (sensitivity = 0.95, specificity = 0.80), while saving 10 (13%) or 11 (15%) patients from a confirmatory biopsy, respectively. CONCLUSIONS Patients with a GPS ≤12 can safely forgo a confirmatory biopsy, as reclassification that may trigger treatment does not frequently occur in this group. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e406 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Daniel Hettel More articles by this author Anna Faris More articles by this author Shree Agrawal More articles by this author Bryan Naelitz More articles by this author Khaled Fareed More articles by this author James Ulchaker More articles by this author Andrew Stephenson More articles by this author Michael Gong More articles by this author Eric Klein More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Purpose: We performed a single center evaluation to compare perioperative, pathological and functional outcomes of robotic partial nephrectomy of T1a renal masses less than vs greater than 2 cm. Materials and Methods: Propensity score 1:1 matching of queried patients was performed using the institutional robotic partial nephrectomy database from January 2007 to January 2017. Matching was done by patient age, gender, race, body mass index, the Charlson comorbidity index, smoking status, diabetes, hypertension, hyperlipidemia, ASA (R) (American Society of Anesthesiologists (R)) score, estimated glomerular filtration rate, chronic kidney disease stage and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar line and abutting main renal artery or vein) score. We analyzed the records of 524 patients, including 262 with a renal mass less than 2 cm vs 262 with a renal mass 2 cm or greater. Perioperative, pathological and functional outcomes were evaluated. Results: Smaller renal masses (less than 2 cm) were associated with significantly lower operative time, blood loss, ischemia time (mean +/- SD 14.3 +/- 9.58 vs 21.5 +/- 9.51 minutes, p < 0.001) and intraoperative transfusions (0% vs 2.7%, p = 0.015). Moreover, we found superior early renal functional outcomes as assessed by the estimated glomerular filtration rate on postoperative day 1 (mean 83.1 +/- 21.3 vs 76.6 +/- 22.0 mg/ml/1.73 m(2), p = 0.001), greater parenchymal preservation (mean 89.9% +/- 9.45% vs 83.6% +/- 8.20%, p < 0.001) and a trend toward a lower rate of postoperative complications (13.5% vs 19.5%, p = 0.080). A higher incidence of malignancy was found in larger tumors (85.9% vs 74.8%, p = 0.002) but no difference was recorded in positive surgical margins. Conclusions: Robotic partial nephrectomy tends to be a low morbidity treatment modality for renal masses less than 2 cm. Although active surveillance is a common option for such tumors, robotic partial nephrectomy remains an alternative in select patients.

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology II1 Apr 2018MP73-09 COMPARATIVE EFFECTIVENESS OF BENIGN PROSTATE ENLARGEMENT INTERVENTIONS AT FACILITATING UROLOGIC MEDICATION DISCONTINUATION Bradley Gill, Navin Sabharwal, James Ulchaker, Khaled Fareed, and Daniel Shoskes Bradley GillBradley Gill More articles by this author , Navin SabharwalNavin Sabharwal More articles by this author , James UlchakerJames Ulchaker More articles by this author , Khaled FareedKhaled Fareed More articles by this author , and Daniel ShoskesDaniel Shoskes More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2373AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Large, comparative effectiveness analyses of transurethral prostate procedures (TUPPs) enabling discontinuation of urologic medications (Rx) are lacking. This study tested the hypothesis that tissue-eliminating procedures confer greater medication discontinuation rates than tissue-necrosing procedures. METHODS All TUPPs in a large tertiary system from 2001-2016 were identified. Demographics, procedure type, and urologic Rx use preoperatively, 3-12 months postoperatively, and over 12 months postoperatively were collected. Tissue-eliminating procedures included transurethral resection (TURP) and laser photovaporization (PVP), tissue-necrosing procedures were microwave (TUMT) and radiofrequency needle ablation (TUNA), with simple prostatectomy (SP) included as a gold-standard comparator. Rx were "discontinued" if no longer an active prescription starting 3 months postoperatively and were "resumed" if ever active following this. Rx were "initiated" if active 3 months or more postoperatively and not active preoperatively. RESULTS A total 5150 TUPPs were analyzed (Table 1). Mean age ranged from 69.1-71.8 years across procedures. Preoperative Rx significantly differed across procedures, except Beta-3 agonist. Alpha blockers were the most common and Beta-3 agonist were the least common Rx preoperatively. Tissue-eliminating TUPPs had greater rates of Rx discontinuation than tissue-necrosing procedures, while the latter had the highest Rx resumption and initiation rates. Alpha blocker and 5-alpha reductase inhibitor discontinuation, resumption, and initiation rates significantly differed across procedures, whereas all but anticholinergic discontinuation rates did, too. Only Beta-3 agonist initiation differed across procedures. Rates of Rx discontinuation were greatest for SP relative to TUPPs and rates of Rx resumption and initiation were lowest for SP compared to TUPPs, as well. CONCLUSIONS Relative to tissue-necrosing transurethral prostate procedures, tissue-eliminating procedures achieved superior rates of urologic medication discontinuation, resumption, and de novo initiation. Simple prostatectomy outperformed all transurethral procedures in these regards. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e994 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Bradley Gill More articles by this author Navin Sabharwal More articles by this author James Ulchaker More articles by this author Khaled Fareed More articles by this author Daniel Shoskes More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Genomic classifiers based on tumor gene expression add to the predictive power of clinicopathologic features in contemporary PCa risk stratification. Increasingly, mpMRI is utilized to identify occult high grade disease as well as to aid in pre-treatment staging of localized disease. We undertook a study to examine the association of tumor gene expression profiles following radical prostatectomy (RP) with radiographic features on pre-prostatectomy mpMRI. We queried an institutional review board-approved research registry of PCa patients who had preoperative 3T mpMRI followed by post-prostatectomy tumor molecular testing performed in the course of clinical care. Genomic testing was not geographically matched to mpMRI detected lesions. Our analysis focused on correlative findings between clinical information, a genomic classifier score, and MRI features. Statistical software was used for statistical modeling of associations between gene signatures, clinicopathologic variables and imaging characteristics. Forty-eight patients met criteria for this analysis. Median age was 67 years (range 45-78) and average pre-op PSA was 11.72. Pathologic findings after RP were: 28 (58%) Gleason Score (GS) 7 (17 were 3+4, 11 were 4+3), 5 (10%) GS 8, 15 (31%) GS 9, 42 (87.5%) had EPE, 15 (31.3%) had SVI, 30 (62.5%) had positive surgical margins (SM), and 13 (27%) were node positive. A majority of patients had pre-op PI-RADS 5 lesions (n=38) detected on mpMRI. No patients had clinically or radiographically suspicious lymph nodes prior to RP. The number of patients with Decipher low, intermediate, and high risk scores were 11 (23%), 11 (23%), and 26 (54%), respectively. Non-parametric testing demonstrated a significant association between Decipher score and PI-RADS score on mpMRI (Kruskal-Wallis Test, p<0.050). Similarly, mean apparent diffusion coefficients (ADC) were directly correlated with Decipher score (Kruskal-Wallis Test, p<0.05). mpMRI features alone did not correlate with positive SM and accounting for Decipher score in univariate or multivariate models did not improve the ability of mpMRI features to predict SM status. Higher post-operative decipher score was, however, associated with likelihood of pathologic node positivity (ANOVA p=0.009). A significant correlation was observed between Decipher scores and PI-RADS classification as well as mean tumor ADC values on mpMRI. A high risk Decipher score was associated with higher rates of pathologic LN positivity otherwise undetected on mpMRI. These data support further validation of genomic classifiers in combination with mpMRI for risk stratifying PCa patients.

Purpose: We determined the effect of 5 alpha-reductase inhibitors on disease reclassification in men with prostate cancer optimally selected for active surveillance. Materials and Methods: In this retrospective review we identified 635 patients on active surveillance between 2002 and 2015. Patients with favorable cancer features on repeat biopsy, defined as absent Gleason upgrading, were included in the cohort. Patients were stratified by those who did or did not receive finasteride or dutasteride within 1 year of diagnosis. The primary end point was grade reclassification, defined as any increase in Gleason score or predominant Gleason pattern on subsequent biopsy. This was assessed by multivariable Cox proportional hazards regression analysis. Results: At diagnosis 371 patients met study inclusion criteria, of whom 70 (19%) were started on 5 alpha-reductase inhibitors within 12 months. Median time on active surveillance was 53 vs 35 months in men on vs not on 5 alpha-reductase inhibitors (p < 0.01). Men on 5 alpha-reductase inhibitors received them for a median of 23 months (IQR 6-37). On actuarial analysis there was no significant difference in grade reclassification for 5 alpha-reductase inhibitor use in patients overall or in the very low/low risk subset. The overall percent of patients who experienced grade reclassification was similar at 13% vs 14% (p = 0.75). After adjusting for baseline clinicopathological features 5 alpha-reductase inhibitors were not significantly associated with grade reclassification (HR 0.80, 95% CI 0.31-1.80, p = 0.62).Furthermore, no difference in adverse features on radical prostatectomy specimens was observed in treated patients (p = 0.36). Conclusions: Among our cohort of men on active surveillance 5 alpha-reductase inhibitor use was not associated with a significant difference in grade reclassification with time.

PURPOSE:We compare intermediate term clinical outcomes among men with favorable risk and intermediate/high risk prostate cancer managed by active surveillance.MATERIALS AND METHODS:A total of 635 men with localized prostate cancer have been on active surveillance since 2002 at a high volume academic hospital in the United States. Median followup is 50.5 months (IQR 31.1-80.3). Time to event analysis was performed for our clinical end points.RESULTS:Of the cohort 117 men (18.4%) had intermediate/high risk disease. Overall 5 and 10-year all cause survival was 98% and 94%, respectively. Cumulative metastasis-free survival at 5 and 10 years was 99% and 98%, respectively. To date no cancer specific deaths had been observed. Overall freedom from intervention was 61% and 49% at 5 and 10 years, respectively. Overall cumulative freedom from failure of active surveillance, defined as metastasis or biochemical failure after local therapy with curative intent, was 97% and 91% at 5 and 10 years, respectively. Of the men 21 (9.9%) experienced biochemical failure after deferred treatment and the 5-year progression-free probability was 92%. Compared to men with favorable risk disease those with intermediate/high risk cancer experienced no difference in metastases, surveillance failure or curative intervention. However, patients at higher risk were at significantly increased risk for all cause mortality, likely reflecting patient selection factors. These conclusions may be limited by the small number of events and the duration of our study.CONCLUSIONS:Patients with localized prostate cancer who are on active surveillance demonstrated a low rate of active surveillance failure, prostate cancer specific mortality and metastases regardless of baseline risk.

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy I1 Apr 2017PD20-04 PERIOPERATIVE OUTCOMES OF ROBOTIC AND OPEN PARTIAL NEPHRECTOMY FOR MODERATELY AND HIGHLY COMPLEX T1B RENAL TUMORS Önder Kara, Matthew J. Maurice, Pascal Mouracade, Ercan Malkoç, Julien Dagenais, Ryan J. Nelson, Jaya Sai Chavali, Khaled Fareed, Robert J. Stein, Amr Fergany, and Jihad H. Kaouk Önder KaraÖnder Kara More articles by this author , Matthew J. MauriceMatthew J. Maurice More articles by this author , Pascal MouracadePascal Mouracade More articles by this author , Ercan MalkoçErcan Malkoç More articles by this author , Julien DagenaisJulien Dagenais More articles by this author , Ryan J. NelsonRyan J. Nelson More articles by this author , Jaya Sai ChavaliJaya Sai Chavali More articles by this author , Khaled FareedKhaled Fareed More articles by this author , Robert J. SteinRobert J. Stein More articles by this author , Amr FerganyAmr Fergany More articles by this author , and Jihad H. KaoukJihad H. Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.890AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic approach is well-accepted standard for cT1a, however some urologists may question it for more complex cT1b lesions. We aimed to compare outcomes between robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN) for moderately or highly complex (RENAL Score ≥7) T1b tumors. METHODS We retrospectively reviewed 1230 consecutive cases, consisting of 823 RPN and 407 OPN, performed for renal mass at a single academic tertiary center between 2011 and 2016. Of these, data on 143 RPN and 78 OPN cases for moderately or highly complex T1b tumors. Baseline patient factors, and tumor characteristics, operative, postoperative, functional and oncologic outcomes were compared between groups. RESULTS Apart from a higher age among OPN cases (59.7 vs. 64.2 yrs. p=0.01), demographic characteristics were similar between groups. No statistically significant differences were seen in tumor size (p=0.54) or margin status (p=0.83) between groups. The patients in the RPN group had less estimated blood loss (150 vs. 300 cc, p<0.01), lower intraoperative transfusion rates (2.1% vs. 12.8%, p<0.01), and shorter length of stay (3 vs. 5 days, p<0.01). Patients who underwent RPN were found to have lower overall (Clavien grade 1-5; 18.9 vs. 39.7 %, p<0.01), and lower major (Clavien grade 3-5; 4.2 vs. 15.4 %, p<0.01) complication rates. Multivariable logistic regression analysis demonstrated open approach (OR 2.8, CI 1.4-5.4, p=0.002) and high BMI (OR 1.05, CI 1.01-1.1, p=0.01) to be independent factors for overall complications. There was no difference in estimated glomerular filtration rate preservation rates between groups for early (p=0.2) and latest (p=0.1) functional follow-up. Oncological outcomes were similar between the two groups. CONCLUSIONS For moderately or highly complex T1b tumors RPN appears to be a safe and effective alternative to OPN with the advantages of shorter length of stay and less blood loss. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e371 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Önder Kara More articles by this author Matthew J. Maurice More articles by this author Pascal Mouracade More articles by this author Ercan Malkoç More articles by this author Julien Dagenais More articles by this author Ryan J. Nelson More articles by this author Jaya Sai Chavali More articles by this author Khaled Fareed More articles by this author Robert J. Stein More articles by this author Amr Fergany More articles by this author Jihad H. Kaouk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...