You have accessJournal of UrologyBladder Cancer: Basic Research IV1 Apr 2015MP68-12 UTILIZING DNA METHYLATION MARKERS TO PREDICT BLADDER CANCER STAGE Chris Duymich, Leonard Dalag, Hooman Djaladat, Sameer Chopra, Kamran Movassaghi, Siamak Daneshmand, Peter Jones, and Gangning Liang Chris DuymichChris Duymich More articles by this author , Leonard DalagLeonard Dalag More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , Sameer ChopraSameer Chopra More articles by this author , Kamran MovassaghiKamran Movassaghi More articles by this author , Siamak DaneshmandSiamak Daneshmand More articles by this author , Peter JonesPeter Jones More articles by this author , and Gangning LiangGangning Liang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2474AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While 70% of bladder cancer (BC) is identified as non-muscle-invasive at initial presentation, progression to muscle-invasive bladder cancer (MIBC) continues to occur in approximately 15% of patients. Unfortunately, transurethral resection of bladder tumors (TURBT) for the diagnosis and staging of BC cannot accurately identify all cases of MIBC, which may delay time to surgery. We seek to address the clinical understaging of bladder cancer by identifying a panel of DNA methylation markers in bladder tumors that may be predictive of stage. METHODS Through an IRB approved protocol, non-invasive bladder tumor blocks from the USC Department of Urology were reviewed for DNA methylation analysis. Following DNA extraction from the tumors, methylation levels at select CpG dinucleotides throughout the genome were detected using the Infinium 450K array technology. In addition, invasive bladder tumor DNA methylation data was obtained from The Cancer Genome Atlas (TCGA). Unsupervised clustering using Ward's method was used to develop a heat map of the most variant probes across tumors. Finally, a multinomial logistic regression model of this data was used to identify differentially methylated CpG sites as predictive markers for normal urothelium, low stage, or high stage tumors. RESULTS We obtained 26 normal urothelium, 63 low stage tumors (Ta-T1), and 130 high stage tumors (T2-T4) that were analyzed for DNA methylation markers. We isolated 2,479 candidate markers of differential DNA methylation with average beta value difference between two sample groups being greater than 0.3 (Figure). A panel of 3 DNA methylation markers was found to predict normal urothelium with 81% accuracy, a panel of 6 DNA methylation markers was found to predict low stage tumors with 91% accuracy, and a panel of 15 DNA methylation markers were found to predict high stage tumors with 98% accuracy. Overall, the model is 94% accurate for the 219 samples analyzed. CONCLUSIONS These results suggest that significant differences in DNA methylation levels exist at specific sites in the human genome for low stage versus high stage BC. Consequently, there is potential to improve the clinical understaging of TURBT specimens utilizing these predictive markers. The next phase of the study is ongoing as we seek externally validate these markers on prospectively collected bladder tumors. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e862 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chris Duymich More articles by this author Leonard Dalag More articles by this author Hooman Djaladat More articles by this author Sameer Chopra More articles by this author Kamran Movassaghi More articles by this author Siamak Daneshmand More articles by this author Peter Jones More articles by this author Gangning Liang More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

ObjectiveTo prospectively evaluate the feasibility and safety of a novel, second‐generation telementoring interface (Connect™; Intuitive Surgical Inc., Sunnyvale, CA, USA) for the da Vinci robot.Materials and MethodsRobotic surgery trainees were mentored during portions of robot‐assisted prostatectomy and renal surgery cases. Cases were assigned as traditional in‐room mentoring or remote mentoring using Connect. While viewing two‐dimensional, real‐time video of the surgical field, remote mentors delivered verbal and visual counsel, using two‐way audio and telestration (drawing) capabilities. Perioperative and technical data were recorded. Trainee robotic performance was rated using a validated assessment tool by both mentors and trainees. The mentoring interface was rated using a multi‐factorial Likert‐based survey. The Mann–Whitney and t‐tests were used to determine statistical differences.ResultsWe enrolled 55 mentored surgical cases (29 in‐room, 26 remote). Perioperative variables of operative time and blood loss were similar between in‐room and remote mentored cases. Robotic skills assessment showed no significant difference (P > 0.05). Mentors preferred remote over in‐room telestration (P = 0.05); otherwise no significant difference existed in evaluation of the interfaces. Remote cases using wired (vs wireless) connections had lower latency and better data transfer (P = 0.005). Three of 18 (17%) wireless sessions were disrupted; one was converted to wired, one continued after restarting Connect, and the third was aborted. A bipolar injury to the colon occurred during one (3%) in‐room mentored case; no intraoperative injuries were reported during remote sessions.ConclusionIn a tightly controlled environment, the Connect interface allows trainee robotic surgeons to be telementored in a safe and effective manner while performing basic surgical techniques. Significant steps remain prior to widespread use of this technology.

OBJECTIVE To evaluate the risk factors, management, and outcomes of benign ureteroenteric strictures (UES) in patients undergoing open radical cystectomy (RC) and urinary diversion for urothelial bladder carcinoma.MATERIALS AND METHODS Using our institutional review boarde-approved institutional bladder cancer database, we identified 1964 patients who underwent RC for urothelial bladder carcinoma between 1971 and 2008. Patients underwent a uniform refluxing ureteroenteric anastomosis technique to ileum. In patients with UES, we reviewed clinicopathologic, management, and outcome variables. A multivariate logistic regression model was used to identify independent UES predictors.RESULTS Forty-nine patients and 51 renal units were retrospectively identified with benign UES (2.6%). Median follow-up was 12.4 years (0.2-27.3 years) and median time from RC to UES diagnosis was 10 months (2 months-10 years). Although one-third were asymptomatic, common presentations included flank pain (22%) and urinary tract infection (9%). Thirty-one patients underwent primary endoscopic treatments, including dilatation and stenting, of whom, 13 patients (42%) underwent secondary endoscopic treatment and 9 patients (29%) underwent open revision. Three patients underwent primary open management. Median glomerular filtration rate did not change after management (49-48 mL/min); however, imaging showed improvement in 50% of cases. A multivariate logistic regression model revealed no association with age, body mass index, Charlson comorbidity index, perioperative radiation or chemotherapy, or preoperative serum albumin in predicting UES.CONCLUSION Benign UES are uncommon after RC and urinary diversion using a consistent meticulous surgical approach. More commonly on the left, UES generally present a few months after RC. Although no specific predisposing factor was determined, surgical technique plays an important role. (C) 2015 Elsevier Inc.

Purpose: We developed a novel procedure specific simulation platform for robotic partial nephrectomy. In this study we prospectively evaluate its face, content, construct and concurrent validity.Materials and Methods: This hybrid platform features augmented reality and virtual reality. Augmented reality involves 3-dimensional robotic partial nephrectomy surgical videos overlaid with virtual instruments to teach surgical anatomy, technical skills and operative steps. Advanced technical skills are assessed with an embedded full virtual reality renorrhaphy task. Participants were classified as novice (no surgical training, 15), intermediate (less than 100 robotic cases, 13) or expert (100 or more robotic cases, 14) and prospectively assessed. Cohort performance was compared with the Kruskal-Wallis test (construct validity). Post-study questionnaire was used to assess the realism of simulation (face validity) and usefulness for training (content validity). Concurrent validity evaluated correlation between virtual reality renorrhaphy task and a live porcine robotic partial nephrectomy performance (Spearman's analysis).Results: Experts rated the augmented reality content as realistic (median 8/10) and helpful for resident/fellow training (8.0-8.2/10). Experts rated the platform highly for teaching anatomy (9/10) and operative steps (8.5/10) but moderately for technical skills (7.5/10). Experts and intermediates outperformed novices (construct validity) in efficiency (p = 0.0002) and accuracy (p = 0.002). For virtual reality renorrhaphy, experts outperformed intermediates on GEARS metrics (p = 0.002). Virtual reality renorrhaphy and in vivo porcine robotic partial nephrectomy performance correlated significantly (r = 0.8, p < 0.0001) (concurrent validity).Conclusions: This augmented reality simulation platform displayed face, content and construct validity. Performance in the procedure specific virtual reality task correlated highly with a porcine model (concurrent validity). Future efforts will integrate procedure specific virtual reality tasks and their global assessment.

You have accessJournal of UrologyPlenary Session IV: Best Abstracts1 Apr 2014PIV-04 CONNECTTM – A PILOT STUDY FOR THE REMOTE PROCTORING OF ROBOTIC SURGERY Daniel H. Shin, Leonard Dalag, Inderbir S. Gill, and Andrew J. Hung Daniel H. ShinDaniel H. Shin More articles by this author , Leonard DalagLeonard Dalag More articles by this author , Inderbir S. GillInderbir S. Gill More articles by this author , and Andrew J. HungAndrew J. Hung More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2548AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES ConnectTM is a novel software accessory that adds remote proctoring ability to the da Vinci robot. The interface allows proctors to provide real-time surgical advice to training surgeons via a live bi-directional audio-visual feed with telestration feature. The purpose of this study was to perform a feasibility study of this interface with traditional in-room proctoring as a control. METHODS Each training surgeon was randomized to in-room or remote proctoring prior to each case. Inclusion criteria: 1) Selected parts of robotic prostatectomy or partial nephrectomy & 2) Available training, supervising and proctoring surgeons. Exclusion was per attending surgeon discretion. Peri-operative objective data and post-case subjective questionnaire data was collected. Trainee performance was assessed with the validated GEARS (Global Evaluative Assessment of Robotic Skills) assessment tool. Statistical comparison was made by Krushkal-Wallace and paired t-tests. RESULTS In the 3-week pilot period, 20 of 32 potential cases were enrolled (62.5%). Operating time for remotely proctored prostatectomy (n=9) was significantly shorter than in-room (n=8) (p=0.02), while EBL was the same (p>0.05). Operating time and EBL was the same for remote (n=3) and in-room (n=1) partial nephrectomies (p>0.05). There was no difference detected between in-room and remote proctor GEARS scores. Proctor and trainee feedback was similar between in-room and remote experiences, except trainees felt remote proctoring enhanced their "confidence as a surgeon” over in-room proctoring (p=0.006) and proctors felt the remote interface was easier to use compared to the in-room mentoring interface (vision cart) (p=0.002). Both proctors and trainees positively rated all aspects of the remote proctoring experience (mean scores 4-5 of 5). There was one complication (bowel serosal injury) during in-room proctoring and one instance in which the remote video feed froze requiring re-connection. CONCLUSIONS In this pilot study we showed that robotic surgery trainees can be effectively and safely proctored in a remote fashion. While definitive conclusions cannot be drawn due to limited sample size, the ConnectTM interface was reviewed favorably compared to in-room mentoring. We will continue to study ConnectTM and its potential for inter-institutional application. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e956 Peer Review Report Advertisement Copyright & Permissions© 2014MetricsAuthor Information Daniel H. Shin More articles by this author Leonard Dalag More articles by this author Inderbir S. Gill More articles by this author Andrew J. Hung More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...