INTRODUCTION AND OBJECTIVE: To describe our surgical technique for single port (SP) transvesical robotic radical prostatectomy using the da Vinci SP ^ a surgical system (Intuitive Surgical, Sunnyvale, CA, USA). METHODS: Sixty-eight patients underwent SP radical prostatectomy through a transvesical approach. Patient selection criteria was localized intermediate risk prostate cancer. Through a 3 cm suprapubic midline incision the bladder was entered and the Da Vinci Single-Port Access Kit was used for access. Floating docking technique was used. Through the access kit, the dedicated multichannel port, an 8 mm assistant port, and the remotely operated suction irrigation system were introduced. The surgical steps for transvesical radical prostatectomy were performed in the following order. 1) Posterior bladder neck dissection, 2) Vas deferens and seminal vesicle dissection, 3) Posterior dissection, 4) Anterior bladder neck and prostate dissection, 5) Pedicle and neurovascular bundle dissection, 6) Posterior Reconstruction and Urethrovesical Anostomosis, 7) removal of prostate through a single incision and bladder closure. RESULTS: Mean patients' age was 62.2 years and the mean preoperative prostate-speci fi c antigen (PSA) was 6.4 ng/mL. Single port robotic transvesical radical prostatectomy was performed successfully in 68 patients successfully without the need for additional port placement or open conversions. Average operative time was 210 minutes. Mean estimated blood loss was 116 mL. Eight patients had positive surgical margins (11.8%). Median length of stay was 4 hours (outpatient setting). Median time with a Foley catheter after surgery was 4.1 days. 46 patients (75.4%) had immediate continence (0-1 pad) after foley removal. Continence rate was 96.7% at postoperative No perioperative or postoperative complications were recorded. CONCLUSIONS: SP transvesical robotic radical prostatectomy is a novel approach that provides advantages including single incision, no additional ports, minimal opioid use, immediate continence, and same day discharge without compromising intraoperative and oncological outcomes.

This chapter introduces the controversy of prostate cancer screening that has emerged over the past two decades, starting with the widespread use of the prostate-specific antigen (PSA) test in 1994. The PSA test revolutionized prostate cancer detection as it is the first biomarker available to physicians to identify prostate cancers that could not be detected by a digital rectal exam. However, unrestricted utilization of the PSA test in asymptomatic men led to an increase in overdiagnosis and treatment-related morbidity. When reviewing evidence relating prostate cancer screening to prostate cancer–related morbidity and mortality, the US Preventative Services Task Force (USPSTF) issued a recommendation in 2012 that screening among asymptomatic men for prostate cancer produces more harm than benefit. These recommendations were updated in 2018 to offer screening selectively for men between the ages of 55 and 69 years. Both recommendations called for physicians to engage patients in shared decision making regarding screening. Consequences of these recommendations on shared decision making, health communication, and efforts to address disparities in screening among underserved and at-risk populations are discussed.

INTRODUCTION AND OBJECTIVE:Women, underrepresented minorities, and international medical graduates are underrepresented in medicine in general and urology specifically. Our objective was to compare...

This chapter introduces the controversy of prostate cancer screening that has emerged over the past two decades, starting with the widespread use of the prostate-specific antigen (PSA) test in 1994. The PSA test revolutionized prostate cancer detection as it is the first biomarker available to physicians to identify prostate cancers that could not be detected by a digital rectal exam. However, unrestricted utilization of the PSA test in asymptomatic men led to an increase in overdiagnosis and treatment-related morbidity. When reviewing evidence relating prostate cancer screening to prostate cancer–related morbidity and mortality, the US Preventative Services Task Force (USPSTF) issued a recommendation in 2012 that screening among asymptomatic men for prostate cancer produces more harm than benefit. These recommendations were updated in 2018 to offer screening selectively for men between the ages of 55 and 69 years. Both recommendations called for physicians to engage patients in shared decision making regarding screening. Consequences of these recommendations on shared decision making, health communication, and efforts to address disparities in screening among underserved and at-risk populations are discussed.

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Prostate & Genitalia (MP35)1 Sep 2021MP35-09 TRANSPERINEAL PROSTATE BIOPSY: THE FIRST ANALYSIS OF THE TRUE PROSTATE MICROBIOME Clay Martin, Pandya Shashank, Annette Lee, and Michael Schwartz Clay MartinClay Martin More articles by this author , Pandya ShashankPandya Shashank More articles by this author , Annette LeeAnnette Lee More articles by this author , and Michael SchwartzMichael Schwartz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002044.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The human microbiome has become a rapidly evolving field of research with health implications in a variety of organ systems. Despite this growing body of literature, little is understood about the microbiome of the prostate. A major difficulty in prostate microbiome research is the difficulty in uncontaminated sample collection. Prior studies have utilized transrectal biopsy cores or surgical pathology specimens, both of which introduce significant contamination. The shift from transrectal to transperineal prostate biopsy technique provides a novel way of obtaining uncontaminated prostate specimens. This study aims to use transperineal prostate biopsy specimens to provide an initial description of the microbiome of the prostate. METHODS: Adult, biopsy-naive men (age 18 and older) who were undergoing elective transperineal prostate biopsy for medically indicated purposes were collected prospectively for inclusion in the study. Those with prior prostate biopsies or surgery, a history of chronic or acute prostatitis, history of chronic pelvic pain, antibiotics within 30 days of biopsy, catheterization within 60 days of biopsy, history of chronic indwelling or clean intermittent catheterizations were excluded such to represent the native bacteria of the unmanipulated gland. In addition to 12-14 diagnostic biopsies, enrolled patients underwent 2 additional biopsies. These core biopsies, along with skin and urine samples were sent directly for microbiome analysis via Illumina 16S Metagenomic sequencing. RESULTS: Prostate tissue samples, voided urine and perineal skin swabs from 10 patients were sent for analysis. 1 prostate biopsy specimen was excluded for suspected contamination. Evidence of a distinct microbiome within the prostate was discovered. Prominent species included Pseudomonas veronii, Comamonas testosteroni and Achromobacter xylosoxidans groups. Phylogenic diversity and weighted UniFrac analysis suggest a significant difference between biopsy specimens and perineal skin swabs but not a significant difference between the biopsy specimens and voided urine samples. CONCLUSIONS: These findings suggest that there exists a distinct microbiome specific to the human prostate gland, which may be closely related to that of bladder urine. Sterile sampling via transperineal ultrasound-guided prostate biopsy represents a viable method of sample collection for microbiome analysis. Further research is needed to further characterize the microbiome of the prostate and to elucidate the potential implications on human health and disease states. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e630-e630 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Clay Martin More articles by this author Pandya Shashank More articles by this author Annette Lee More articles by this author Michael Schwartz More articles by this author Expand All Advertisement Loading ...

You have accessJournal of UrologyEducation Research I (PD02)1 Sep 2021PD02-05 ARE THERE GENDER DIFFERENCES IN UROLOGY RESIDENT'S SURGICAL AUTONOMY? Daniel Nethala, Leah Beland, Manish Vira, David Chan, Michael Schwartz, Simon Hall, Louis Kavoussi, and Jessica Kreshover Daniel NethalaDaniel Nethala More articles by this author , Leah BelandLeah Beland More articles by this author , Manish ViraManish Vira More articles by this author , David ChanDavid Chan More articles by this author , Michael SchwartzMichael Schwartz More articles by this author , Simon HallSimon Hall More articles by this author , Louis KavoussiLouis Kavoussi More articles by this author , and Jessica KreshoverJessica Kreshover More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001966.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Discrimination against women in surgical training has been subjectively described for decades. Despite significant growth over the years, Urology continues to have one of the lowest representations of practicing female physicians at 10%. Given this striking disproportion, it is unclear if any differences exist between the surgical autonomy given to male and female residents during training. To study this, we compared the surgical autonomy of male and female urology residents for common urologic procedures using a real-time smart phone application. METHODS: The myTIPreport mobile application was used from 12/2018-1/2021 at a single academic urology training program. The pooled database was queried for attending evaluations assessing the perceived autonomy of residents for four procedures: Transurethral resection of prostate (TURP), Transurethral resection of bladder tumor (TURBT), Robotic Radical Prostatectomy (RALP), Laparoscopic Nephrectomy (LNx). The Zwisch scale of autonomy was used to rate residents from 1 to 5 based on the attending's perception of the resident's autonomy, ranging from Observation Only to Expert Surgeon. The scored evaluations for each procedure were then separated based on the resident's gender and the mean values for each gender were calculated. A student's t-test was performed to determine if there existed a difference in the mean ratings between genders for each procedure. RESULTS: During the study period, there were a total of 12 male and 6 female residents with myTIPreport evaluations available for analysis. For the procedures TURP, TURBT, RALP, and LNx there were 101, 99, 59, and 65 male resident evaluations and 27, 36, 34, 27 female evaluations respectively. For TURP, TURBT, and RALP, there were no significant differences in the attending's perception of the resident's surgical autonomy regardless of gender (all p>0.05). For LNx, male residents were seen as more surgically autonomous than female residents (p=0.004). CONCLUSIONS: For the procedures TURP, TURBT, and RALP there were no differences in the surgical autonomy of male and female residents. For LNx, male residents were seen as more surgically autonomous than females. More data is needed to determine if individual attendings differed significantly in their scoring of resident autonomy based on gender, if the attendings gender or age played a role in the evaluation of autonomy, and to match male and female residents based on case volumes and graduation year. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e39-e39 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Nethala More articles by this author Leah Beland More articles by this author Manish Vira More articles by this author David Chan More articles by this author Michael Schwartz More articles by this author Simon Hall More articles by this author Louis Kavoussi More articles by this author Jessica Kreshover More articles by this author Expand All Advertisement Loading ...

INTRODUCTION AND OBJECTIVE:There is limited data demonstrating the efficacy of laparoscopic training curricula, such as BLUS (Basic Laparoscopic Urologic Skills), in improving technical skills. Des...

You have accessJournal of UrologySurgical Technology & Simulation: Training & Skills Assessment I (MP34)1 Apr 2020MP34-07 CORRELATING CROWD-SOURCED ASSESSMENT OF TECHNICAL SKILLS (CSATS) WITH POST-OPERATIVE COMPLICATION RATES IN UROLOGIC ROBOTIC SURGERY Joseph Sarcona*, David Mikhail, Aaron Tabibzadeh, Daniel Nassau, Zachary Kozel, Manish Vira, Michael Schwartz, Michael Feuerstein, Kreshover Jessica, Louis Kavoussi, and Lee Richstone Joseph Sarcona*Joseph Sarcona* More articles by this author , David MikhailDavid Mikhail More articles by this author , Aaron TabibzadehAaron Tabibzadeh More articles by this author , Daniel NassauDaniel Nassau More articles by this author , Zachary KozelZachary Kozel More articles by this author , Manish ViraManish Vira More articles by this author , Michael SchwartzMichael Schwartz More articles by this author , Michael FeuersteinMichael Feuerstein More articles by this author , Kreshover JessicaKreshover Jessica More articles by this author , Louis KavoussiLouis Kavoussi More articles by this author , and Lee RichstoneLee Richstone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000878.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: CSATS, a validated crowd sourced Global Evaluative Assessment of Robotic Skills scoring system, is a voluntary robotic surgery technical skills evaluation designed for surgeon feedback and quality. While CSATS has correlated with technical outcomes such as anastomotic leaks following robotic prostatectomy, there is a paucity of data comparing it to surgical complications in urology. We aimed to compare CSTATS score with complications after robotic urologic surgery. METHODS: Our prospectively maintained robotic surgery complication database was retrospectively reviewed and compared to CSATS data for urologists in our health system. Fellowship trained surgeons with a minimum of 10 cases submitted to CSATS with complete complication data were included for analysis. CSATS score and surgeon quartiles were compared to total and ≥ Clavien grade 3 complications. RESULTS: In 2018-19, a total of 196 urology cases were submitted to CSATS in our health system. Of these, 125 cases by 4 fellowship trained urologists had complete complication data from a historical robotic complications database. These CSATS cases included prostate (75%), bladder (10%), upper tract (13%), and other (2%) procedures. The same 4 surgeons completed 315 robotic cases from 2015-2018 with an overall total complication rate of 20.3% (13-32%), with 8.9% (6-14%) Clavien 3 complications. The mean CSATS score was 20.26 (20.18 to 20.43). Of the four surgeons, 2 were in the 3rd and 2 in the top quartiles overall for their procedures. CSATS score correlated with total and ≥ Clavien 3 complications with Pearson coefficients of -0.926 (R2 0.858) and -0.556 (R2 0.310) respectively (Fig. 1). Being in the top quartile did not significantly reduce ≥Clavien 3 complications (6.3% vs. 12.1%, p=0.07) using chi-squared analysis. CONCLUSIONS: To our knowledge, this is the first assessment comparing CSATS scores to complication rates in robotic urologic surgery. Overall complication rate was strongly correlated to CSATS score. Significant complications weakly correlated to CSATS score, but approached significance with surgeon quartiles. With these preliminary metrics, we are currently evaluating the correlation of technical skills and complication rates across all robotic procedures in our health system. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e505-e505 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph Sarcona* More articles by this author David Mikhail More articles by this author Aaron Tabibzadeh More articles by this author Daniel Nassau More articles by this author Zachary Kozel More articles by this author Manish Vira More articles by this author Michael Schwartz More articles by this author Michael Feuerstein More articles by this author Kreshover Jessica More articles by this author Louis Kavoussi More articles by this author Lee Richstone More articles by this author Expand All Advertisement PDF downloadLoading ...

INTRODUCTION AND OBJECTIVE: The goal of surgical residency is to create independently operating surgeons. The Accreditation Council for Graduate Medical Education (ACGME) has designated minimum case numbers that surgical resident must meet prior to graduation. While these case numbers are the benchmark for graduation as an independent surgeon, there is no data in the literature assessing if these numbers hold evidence for urology residents. To study this, we compared urology resident's autonomy during two common procedures to their number of cases logged for each procedure using a real-time smart phone application. METHODS: We utilized the myTIPreport mobile application from 12/18-11/19. Attending evaluations were logged post-operatively assessing the perceived autonomy of PGY 2's & 3's for transurethral bladder tumor resections (TURBT) and Ureteroscopies (URS). The Zwisch scale was used to assess the perceived autonomy. Independence was calculated as an autonomy score of Supervision Only or higher. Each myTIPreport evaluation was correlated with the number of cases logged for each individual procedure in the ACGME case logs at the time of evaluation and recorded. RESULTS: A total of 101 paired evaluations, 33 for TURBT and 68 for URS, from 5 residents were analyzed. For TURBT's, all residents received a rating of Supervision Only at least twice prior to the ACGME minimum required case number of 100 for Transurethral cases. For URS, all residents (4/4) with evaluations before the ACGME minimum required case number of 60 received a rating of Supervision Only at least once. CONCLUSIONS: For the procedures TURBT and URS, residents achieved surgical independence before the ACGME minimum case number. In the case of TURBT, residents were seen as independent much earlier than the designated ACGME case minimum, whereas for URS the minimum case number was an adequate benchmark for surgical independence. More data is needed to determine at what case number there is a progression in autonomy for each specific step of the case to best tailor resident specific educational needs.Source of Funding: None

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI1 Apr 2017PD66-08 PARTIAL NEPHRECTOMY IS ASSOCIATED WITH INCREASED RECURRENCE RISK AMONG CLINICAL STAGE T1 UPSTAGED TO PATHOLOGIC T3A RENAL CELL CARCINOMA Paras Shah, Daniel Moreira, Vinay Patel, Arvin George, Geoffrey Gaunay, Manaf Alom, Michael Schwartz, Manish Vira, Lee Richstone, and Louis Kavoussi Paras ShahParas Shah More articles by this author , Daniel MoreiraDaniel Moreira More articles by this author , Vinay PatelVinay Patel More articles by this author , Arvin GeorgeArvin George More articles by this author , Geoffrey GaunayGeoffrey Gaunay More articles by this author , Manaf AlomManaf Alom More articles by this author , Michael SchwartzMichael Schwartz More articles by this author , Manish ViraManish Vira More articles by this author , Lee RichstoneLee Richstone More articles by this author , and Louis KavoussiLouis Kavoussi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2971AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To compare recurrence-free survival (RFS) of partial nephrectomy (PN) versus radical nephrectomy (RN) for clinical stage T1 (cT1) renal cell carcinoma (RCC) with pathologic upstaging to T3a among all comers and stratified by pT3a histologic subgroups. METHODS A retrospective analysis of 1250 patients undergoing PN or RN for cT1 RCC upstaged to pT3a was performed. Baseline characteristics were compared between treatment groups with chi-square and Student t test. RFS was estimated with the Kaplan-Meier method and evaluated as a function of treatment with log-rank test and Cox models adjusting for clinicopathologic variables. RESULTS A total of 140 (11.2%) cT1 cases were upstaged to pT3a, 49 (3.9%) after PN and 91 (7.3%) RN. RN cases had greater mean tumor size (5.5cm vs 4.2cm, p<0.001), were more likely to be of moderate/high anatomic complexity (78% vs 45%, p<0.001) and clear cell histology (95 vs 84%, P=0.035), and less likely to demonstrate positive margins (0% vs 15%, p<0.001, Table). Upstaging in RN was more frequent due to sinus fat (53% vs 14%, p<0.001) or venous invasion (45% vs 8%, p<0.001) and less frequent due to perinephric fat invasion (35% vs 80%, p<0.001, Table 1) compared to PN. PN was associated with higher recurrence risk in pT3a RCC (HR=2.04, P=0.019, Figure). Similar results were found in multivariable analysis (HR=3.17, P=0.003). After stratification by pT3a histology, PN was associated with lower RFS in perinephric (P=0.002) and sinus fat invasion (P=0.046, Figure). CONCLUSIONS PN is associated with higher recurrence risk in cT1 RCC upstaged to pT3a. Patients at high risk for pT3a upstaging may benefit from RN. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1274 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Paras Shah More articles by this author Daniel Moreira More articles by this author Vinay Patel More articles by this author Arvin George More articles by this author Geoffrey Gaunay More articles by this author Manaf Alom More articles by this author Michael Schwartz More articles by this author Manish Vira More articles by this author Lee Richstone More articles by this author Louis Kavoussi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology III1 Apr 2016MP34-01 DEVELOPMENT AND DISSEMINATION OF A LOW COST THREE-DIMENSIONALLY PRINTED LAPAROSCOPIC TRAINER Renai Yoon, Zhamshid Okhunov, Benjamin Dolan, Michael J. Schwartz, Paras H. Shah, Hannah Bierwiler, Kamaljot Kaler, Ralph Clayman, and Jaime Landman Renai YoonRenai Yoon More articles by this author , Zhamshid OkhunovZhamshid Okhunov More articles by this author , Benjamin DolanBenjamin Dolan More articles by this author , Michael J. SchwartzMichael J. Schwartz More articles by this author , Paras H. ShahParas H. Shah More articles by this author , Hannah BierwilerHannah Bierwiler More articles by this author , Kamaljot KalerKamaljot Kaler More articles by this author , Ralph ClaymanRalph Clayman More articles by this author , and Jaime LandmanJaime Landman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1559AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The UCiTrainer is a low cost, portable laparoscopic trainer that utilizes an electronic tablet for video and optics; it can be printed with a consumer-level three-dimensional (3D) printer. We report our initial experience on the feasibility of using 3D printing technology as a novel method of manufacturing and distribution for low cost, surgical education tools on a global on demand basis. METHODS We created computer-aided designs (CAD) using Solidworks Software (Dassault Systemes Solidworks Corp., Velizy-Villacoublay, France) for nine separate components which could then be assembled into a laparoscopic training device including an instrument port mold. These files were provided to two remote institutions to 3D print and assemble the trainer. The CAD files were uploaded to Makerware software (MakerBot Industries, New York City, NY) to be sliced into layers and prepared for printing. All pieces were printed using a Flashforge Creator 3D printer (Flashforge, Jinhua, China) in five separate prints. The following printer settings were used: raft layer, 15% infill, 2 shells, 0.10 mm layer height, 230 ? C extruder, 110 ? C build plate, 90 mm/s extrusion and 150 mm/s travel. In this process, successive layers of a heated, acrylonitrile butadiene styrene filament were extruded and laid on top of one another in both the horizontal and vertical axis. The printed mold was used to create two instrument ports using a liquid silicone rubber. Both remote institutions were provided oral and written instructions for assembly of the components. RESULTS Initial attempts of 3D printing of the larger pieces (Figure 1b) were not successful due to deformation of the plastic. Additionally, initial calibration and leveling of the 3D printer were challenging to novices. Accordingly, the build plate was increased to 120 ? C and a full enclosure was made for the 3D printer to retain heat during the printing process. With these adjustments, successful printing of the components was accomplished. Both institutions were subsequently able to completely assemble and use the training device using only the oral and written instructions provided. CONCLUSIONS 3D printing technology can be used successfully to disseminate a training device for use in surgical education. The device is inexpensive and can be made on an as-needed basis. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e471 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Renai Yoon More articles by this author Zhamshid Okhunov More articles by this author Benjamin Dolan More articles by this author Michael J. Schwartz More articles by this author Paras H. Shah More articles by this author Hannah Bierwiler More articles by this author Kamaljot Kaler More articles by this author Ralph Clayman More articles by this author Jaime Landman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI1 Apr 2016PD48-12 PROGNOSTIC STRATIFICATION OF PATHOLOGIC STAGE T3A RENAL CELL CARCINOMA AFTER RADICAL NEPHRECTOMY Manaf Alom, Paras Shah, Daniel Moreira, Arvin George, Nikhil Waingankar, Sophie Sohval, Fatima-Zahra Jelloul, Oksana Yaskiv, Michael Schwartz, Manish Vira, Joph Steckel, Lee Richstone, and Louis Kavoussi Manaf AlomManaf Alom More articles by this author , Paras ShahParas Shah More articles by this author , Daniel MoreiraDaniel Moreira More articles by this author , Arvin GeorgeArvin George More articles by this author , Nikhil WaingankarNikhil Waingankar More articles by this author , Sophie SohvalSophie Sohval More articles by this author , Fatima-Zahra JelloulFatima-Zahra Jelloul More articles by this author , Oksana YaskivOksana Yaskiv More articles by this author , Michael SchwartzMichael Schwartz More articles by this author , Manish ViraManish Vira More articles by this author , Joph SteckelJoph Steckel More articles by this author , Lee RichstoneLee Richstone More articles by this author , and Louis KavoussiLouis Kavoussi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2734AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Extension of renal cell carcinoma (RCC) beyond the kidney by perinephric (PFI) or sinus fat invasion (SFI) and/or renal vein involvement defines pathologic T3a (pT3a). Although pT3a is associated with worse prognosis compared to localized tumors, not all pT3a develop local recurrence or progression to metastatic disease after radical nephrectomy (RN). Herein, we evaluate the association of PFI, SFI, renal vein thrombosis (RVT), and combination of the above with time to recurrence among patients with pT3a RCC after RN. METHODS We retrospectively reviewed 107 patients who underwent RN between 2006 and 2013 for T3aN0M0 RCC. Recurrence-free survival was estimated using the Kaplan-Meier method. The association of PFI, SFI and RVT independently and in any combination with time to recurrence was evaluated using log-rank and Cox proportional hazards models adjusting for tumor size, grade, histology, age, and type of surgery (laparoscopic vs open). RESULTS Overall, 20 (19%) patients had isolated PFI, 23 (21%) had isolated SFI, 20 (19%) had isolated RVT, and 44 (41%) multiple histologic features. A total of 29 total recurrences (27.1%) were observed over a median follow up of 32 months (interquartile range [IQR] = 19-51). Median time to recurrence was 13 months (IQR = 6-21). No recurrences occurred among patients with isolated PFI; intermediate recurrence-free survival was observed for those with isolated SFI and RVT, while those with multiple histologic features had worst prognosis (Figure, log-rank P=0.003). In multivariable analysis, compared to those with SFI alone, those with isolated RVT had similar risk of recurrence (HR=2.34, 95% CI=0.56-9.84, P=0.247), while those with multiple histologic features had a significantly higher risk of recurrence (HR=3.53, 95% CI=1.09-11.38, P=0.035). PFI alone was not evaluated given no patients developed recurrence. CONCLUSIONS Isolated PFI on RN specimen is a relatively indolent histologic feature compared to SFI and RVT, both of which confer increased risk of recurrence after RN. Presence of multiple pT3a histologic features portends even worse oncologic outcomes. These findings may help better stratify T3a RCC based on the risk of recurrence. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1179-e1180 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Manaf Alom More articles by this author Paras Shah More articles by this author Daniel Moreira More articles by this author Arvin George More articles by this author Nikhil Waingankar More articles by this author Sophie Sohval More articles by this author Fatima-Zahra Jelloul More articles by this author Oksana Yaskiv More articles by this author Michael Schwartz More articles by this author Manish Vira More articles by this author Joph Steckel More articles by this author Lee Richstone More articles by this author Louis Kavoussi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Objective: Contemporary prostate cancer (PCa) screening modalities such as prostate specific antigen (PSA) and digital rectal examination (DRE) are limited in their ability to predict the detection of clinically significant disease. Multi-parametric magnetic resonance imaging (mpMRI) of the prostate has been explored as a staging modality for PCa. Less is known regarding its utility as a primary screening modality. We examined our experience with mpMRI as both a screening and staging instrument.Methods: mpMRI studies performed between 2012 and 2014 in patients without PCa were cross-referenced with transrectal ultrasonography (TRUS) biopsy findings. Statistical analyses were performed to determine association of mpMRI findings with overall cancer diagnoses and clinically significant (Gleason score >= 7) disease. Subgroup analyses were then performed on patients with a history of prior negative biopsy and those without a history of TRUS biopsy. mpMRI studies were also cross-referenced with RP specimens. Statistical analyses determined predictive ability of extracapsular extension (ECE), seminal vesicle involvement (SVI), and pathologic evidence of clinically significant disease (Gleason score >= 7).Results: Four hundred biopsy naive or prior negative biopsy patients had positive mpMRI studies. Overall sensitivity, specificity, positive and negative predictive values were 94%, 37%, 58%, and 87%, respectively and 95%, 31%, 42%, and 93%, respectively for overall cancer detection and Gleason score >= 7 disease. In patients with no prior biopsy history, mpMRI sensitivity, specificity, positive and negative predictive values were 94%, 36%, 65%, and 82%, for all cancers, and 95%, 30%, 50%, and 89% for Gleason score >= 7 lesions, respectively. In those with prior negative biopsy sensitivity, specificity, positive and negative predictive values were 94%, 37%, 52%, and 90% for all cancers, and 96%, 32%, 36%, and 96% for Gleason score >= 7 lesions, respectively. Seventy-four patients underwent radical prostatectomy (RP) after mpMRI. Lesion size on mpMRI correlated with the presence of Gleason score >= 7 cancers (p Z 0.005). mpMRI sensitivity, specificity, positive and negative predictive values were 84%, 39%, 81%, and 44% respectively, for Gleason >= 7 cancer. For ECE and SVI, sensitivity and specificity were 58% and 98% and 44% and 97%, respectively.Conclusion: mpMRI is an accurate predictor of TRUS biopsy and RP outcomes. mpMRI has significant potential to change PCa management, particularly in the screening population, in whom a significant proportion may avoid TRUS biopsy. Further studies are necessary to determine how mpMRI should be incorporated into the current PCa screening and staging paradigms. (C) 2017 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V.

You have accessJournal of UrologyKidney Cancer: Basic Research & Pathophysiology II1 Apr 2016MP85-17 EPITHELIAL-TO-MESENCHYMAL TRANSFORMATION IN THE NEGATIVE SURGICAL MARGIN MAY PREDICT RECURRENCE AFTER NEPHRON-SPARING SURGERY FOR RENAL CELL CARCINOMA Paras Shah, Oksana Yaskiv, Manaf Alom, Arvin George, Daniel Moreira, Vinay Patel, Michael Schwartz, Lee Richstone, Manish Vira, and Louis Kavoussi Paras ShahParas Shah More articles by this author , Oksana YaskivOksana Yaskiv More articles by this author , Manaf AlomManaf Alom More articles by this author , Arvin GeorgeArvin George More articles by this author , Daniel MoreiraDaniel Moreira More articles by this author , Vinay PatelVinay Patel More articles by this author , Michael SchwartzMichael Schwartz More articles by this author , Lee RichstoneLee Richstone More articles by this author , Manish ViraManish Vira More articles by this author , and Louis KavoussiLouis Kavoussi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2283AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Tumor recurrence after partial nephrectomy (PN) can occur in the setting of a negative surgical margin. Although microscopic foci of metastasis at the time of extirpation may be responsible for relapse, an alternative hypothesis is progression of premalignant cells surrounding the primary lesion that are not amenable to detection with conventional histopathologic assessment. As epithelial-to-mesenchymal transition has been implicated in the pathogenesis of renal cell carcinoma (RCC), we evaluate for similar phenotypic change in the benign peri-tumoral tissue of patients who experience relapse after PN. METHODS We reviewed cases of pT1-3aN0M0 RCC undergoing PN at our institution between 2006 and 2013. PN specimens were retrieved for patients with a negative surgical margin who developed regional or systemic recurrence as well as for a control cohort who did not recur. Groups were matched for tumor stage, size, Fuhrman grade, and follow-up. All lesions were clear-cell variant. Malignant and adjacent benign tissue were analyzed for markers of mesenchymal differentiation using immunohistochemistry. Expression of various mesenchymal antigens in the surgical margin was compared between groups based on recurrence status using Fisher's exact test. RESULTS 21 patients with a negative surgical margin who recurred after PN were compared to 17 patients who remain disease-free. E-cadherin expression was significantly decreased in the normal-appearing renal parenchymal margin of patients who developed recurrence compared to those who did not recur (62% versus 6% respectively, p<0.001). Downregulation of E-cadherin was similar between local and systemic recurrence groups. Expression of other markers of mesenchymal differentiation, including vimentin, smooth muscle antigen, and beta-catenin was not associated with recurrence status. CONCLUSIONS Down regulation of E-cadherin in the benign-appearing renal parenchyma surrounding a primary tumor may represent an early premalignant change associated with recurrence after NSS for RCC. Immunohistochemical assessment of the surgical margin for E-cadherin expression offers a prognostic tool that may enhance the ability of other pathologic metrics to identify groups at highest risk for relapse. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1104 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Paras Shah More articles by this author Oksana Yaskiv More articles by this author Manaf Alom More articles by this author Arvin George More articles by this author Daniel Moreira More articles by this author Vinay Patel More articles by this author Michael Schwartz More articles by this author Lee Richstone More articles by this author Manish Vira More articles by this author Louis Kavoussi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyFemale Voiding Dysfunction1 Apr 2015V2-07 ROBOTIC-ASSISTED VESICOVAGINAL FISTULA REPAIR AND RIGHT URETERAL REIMPLANT Christopher Hartman, Paras Shah, Akinwunmi Carons, Michael Schwartz, and Farzeen Firoozi Christopher HartmanChristopher Hartman More articles by this author , Paras ShahParas Shah More articles by this author , Akinwunmi CaronsAkinwunmi Carons More articles by this author , Michael SchwartzMichael Schwartz More articles by this author , and Farzeen FirooziFarzeen Firoozi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.332AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Vesicovaginal fistulas have been described as the result of complications during childbirth, injury during pelvic surgical procedures, following radiation, and after trauma. Numerous techniques for the management of postoperative vesicovaginal fistulas have been demonstrated. Associated genitourinary injuries must be ruled out, and can usually be addressed at the same time as the repair of the fistula. We present the case of a 50-year old female who underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy for benign disease with a delayed diagnosis of a right ureteral injury and bladder injury resulting in a vesicovaginal fistula. Our objective is to demonstrate the use of robotic surgery in the combined repair of a vesicovaginal fistula and right ureteral reimplant. METHODS A cystoscopy was performed which demonstrated a large fistula at the posterior portion of the dome of the bladder. A right retrograde pyelogram was attempted, demonstrating a very short blind-ending ureteral segment, with most contrast returning into the bladder. An antegrade pyelogram was performed through an indwelling right percutaneous nephrostomy tube, demonstrating a distal blind-ending ureter. A Kelly clamp was passed into the vagina and through the fistula, and a ureteral catheter was then passed through the cystoscope and grasped by the clamp, thereby establishing access through the fistula. The fistula was then approached through the abdomen via robotic assistance. The vaginal cuff was entered, exposing the fistula and the lumen of both the vagina and the bladder. The vaginal defect was closed in one layer, while the bladder defect was closed in two layers. A peritoneal flap was created and interposed between the two repairs. The right ureter was then dissected down to the level of dense adhesions and was freed from these attachments and then reimplanted at the dome of the bladder. A Foley catheter was placed and filled with saline, demonstrating no extravasation from either the ureteral reimplant or bladder repair. RESULTS The procedure took 270 minutes and estimated blood loss was 200 cc. A Foley catheter was left in place for 15 days, at which time a cystogram demonstrated no extravasation from the bladder repair and reimplanted right ureter, and the catheter was removed. The patient is continent and pleased with her surgical results. CONCLUSIONS A robotic-assisted laparoscopic approach to combined vesicovaginal fistula repair with ureteral reimplantation is a safe and effective minimally-invasive procedure for a patient with an associated vesicovaginal fistula and ureteral injury. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e99-e100 Peer Review Report Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Hartman More articles by this author Paras Shah More articles by this author Akinwunmi Carons More articles by this author Michael Schwartz More articles by this author Farzeen Firoozi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyKidney Cancer: Localized V1 Apr 2014MP64-19 OFF-CLAMP LAPAROSCOPIC PARTIAL NEPHRECTOMY: LONG TERM RENAL FUNCTIONAL OUTCOMES Paras Shah, Manaf Alom, Arvin George, Louis Kavoussi, Lee Richstone, Daniel Moreira, Mathew Fakhoury, Nithin Theckumparampil, Nikhil Wainganker, Sammy Elsamra, Jessica Kreshover, Soroush Rais-Bahrami, Michael Schwartz, and Simpa Salami Paras ShahParas Shah More articles by this author , Manaf AlomManaf Alom More articles by this author , Arvin GeorgeArvin George More articles by this author , Louis KavoussiLouis Kavoussi More articles by this author , Lee RichstoneLee Richstone More articles by this author , Daniel MoreiraDaniel Moreira More articles by this author , Mathew FakhouryMathew Fakhoury More articles by this author , Nithin TheckumparampilNithin Theckumparampil More articles by this author , Nikhil WaingankerNikhil Wainganker More articles by this author , Sammy ElsamraSammy Elsamra More articles by this author , Jessica KreshoverJessica Kreshover More articles by this author , Soroush Rais-BahramiSoroush Rais-Bahrami More articles by this author , Michael SchwartzMichael Schwartz More articles by this author , and Simpa SalamiSimpa Salami More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1936AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Off-clamp laparoscopic partial nephrectomy has been demonstrated to better preserve renal function than with complete hilar control. These studies, however, are based on short-term follow up. Herein, we sought to compare renal functional outcomes between off-clamp and the traditional on-clamp approach with extended followup in patients who underwent laparoscopic partial nephrectomy for solitary renal masses. METHODS A retrospective review of 551 patients who underwent laparoscopic partial nephrectomy between 2006 and 2011 was performed. Patient demographics and perioperative outcomes were recorded. Univariate regression analysis was used to model each outcome of interest, absolute GFR, absolute change in GFR, and percent change in GFR, as a function of clamp status. Comparison between on and off-clamp was performed at two years and five years followup. RESULTS 86 on-clamp and 45 off-clamp, with atleast four year followup met inclusion criteria for five year renal functional outcomes comparison. Median followup amongst these patients was 57 months. There was no significant difference in tumor size (3.37cm vs. 2.98cm, p = 0.21), tumor volume (36.5cm3 vs. 35.0cm3, p =0.8) between on-clamp and off-clamp cohorts. Both groups were also matched with respect to preoperative patient characteristics. Mean warm ischemia time (WIT) was 25 minutes in the clamped group. A significant overall decrease in GFR of 7cc/min was observed at five year followup amongst all patients. However, no significant association between absolute GFR (70.1ml/min vs. 70.9ml/min, p=0.8), absolute decrease in GFR (-6.5ml/min vs. -8.4ml/min, p=0.53), and percent decrease in GFR (-7.2% vs. -10.4%, p=0.46) was appreciated between on-clamp and off-clamp cohorts. CONCLUSIONS The early benefit afforded by off-clamp laparoscopic partial nephrectomy equilibrates with time revealing no demonstrable differences in renal function with greater than two years followup. Renal Functional Comparison at 5 year Followup (n = 131) Off-Clamp (n = 45) On-Clamp (n = 86) p-value GFR 5 years (95% CI) 70.9 (63.9, 79.9) 70.1 (65.7, 74.3) NS Δ Estimated GFR 5 years (95% CI) -8.4 (-13.1, -3.6) -6.5 (-10.1, -2.8) NS %Δ Estimated GFR 5 years (95% CI) -10.4 (-17.0, -3.8) -7.2 (-12.5, -1.9) NS © 2014FiguresReferencesRelatedDetails Volume 191 Issue 4S April 2014 Page: e707-e708 Advertisement Copyright & Permissions© 2014Metrics Author Information Paras Shah More articles by this author Manaf Alom More articles by this author Arvin George More articles by this author Louis Kavoussi More articles by this author Lee Richstone More articles by this author Daniel Moreira More articles by this author Mathew Fakhoury More articles by this author Nithin Theckumparampil More articles by this author Nikhil Wainganker More articles by this author Sammy Elsamra More articles by this author Jessica Kreshover More articles by this author Soroush Rais-Bahrami More articles by this author Michael Schwartz More articles by this author Simpa Salami More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...