You have accessJournal of UrologyBladder Cancer: Invasive III1 Apr 2017PD36-07 RESTRICTIVE TRANSFUSION IN RADICAL CYSTECTOMY IS SAFE Sumeet Syan-Bhanvadia, Swar Shah, Jie Cai, Gus Miranda, and Siamak Daneshmand Sumeet Syan-BhanvadiaSumeet Syan-Bhanvadia More articles by this author , Swar ShahSwar Shah More articles by this author , Jie CaiJie Cai More articles by this author , Gus MirandaGus Miranda More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1556AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To determine the safety of a restrictive transfusion protocol (RTP) in patients radical cystectomy (RC) patients that are typically elderly with significant co-morbidity, given that perioperative blood transfusion (PBT) has been linked to poorer oncologic outcomes in this setting. METHODS Outcomes for 173 consecutive patients meeting inclusion criteria undergoing RC for urothelial carcinoma (UC) from April 2010 to June 2014 by a single surgeon employing RTP were analyzed from an IRB approved, prospectively collected database. RESULTS Outcomes for 173 consecutive patients meeting inclusion criteria undergoing RC for urothelial carcinoma (UC) from April 2010 to June 2014 by a single surgeon employing RTP were analyzed from an IRB approved, prospectively collected database. Results: Median follow-up was 3.1 years (range=0-5.1 years). Median age was 70 years (38-93). 46 patients (26.6%) received PBT. PBT patients had higher EBL (500 vs. 350, p=0.001), lower baseline hematocrit (28.9 vs. 33.3, p=0.005), and similar operative time (5.8 vs. 5.3 hours, p=0.01) and LOS (5.5 vs. 5, p=0.07). At discharge and 3 week follow-up there was no difference in hematocrit (p>0.05). In the no PBT group 90-day (65.6 vs. 86.7%, p=0.007) and high grade (15.6 vs. 34.8%, p=0.003) complication rates were lower. There were no differences in cardiac complication rates. On multivariable analysis predictors of PBT were age (OR=1.06, 95% CI [1.01, 1.11]), CCMI =2 (OR=2.68, CI [1.09-7.04]), neoadjuvant chemotherapy (OR=3.74, CI [1.46, 10.19]), =pT3 (OR=5.5, CI [2.33, 13.73]), baseline hematocrit (OR=0.95, CI [0.87, 1.00]) and EBL, although marginally (OR=1.001, CI [1, 1.003]). PBT was associated with lower RFS (HR=2.16, CI [1.13, 41.12], p=0.02) (Figure 1) and OS (HR=2.25, CI [1.25, 4.88], p=0.01)(Figure 2). CONCLUSIONS The use of RTP in RC is safe. PBT was associated with poorer RFS and OS independent of clinicopathologic characteristics. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e671 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Sumeet Syan-Bhanvadia More articles by this author Swar Shah More articles by this author Jie Cai More articles by this author Gus Miranda More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Introduction and objective: Perioperative blood transfusion (PBT) is commonplace in radical cystectomy (RC) and has been linked to poorer oncologic outcomes. Limiting PBT in this largely elderly and comorbid population has not been studied. Herein, we first investigate the safety of a restrictive transfusion protocol (RTP) in patients undergoing RC for urothelial carcinoma and then compare oncologic outcomes between patients who did and did not receive PBT.Methods: Outcomes for 173 consecutive patients meeting inclusion criteria undergoing RC for urothelial carcinoma from April 2010 to June 2014 by a single surgeon employing RTP were analyzed from an institutional review board approved, prospectively collected database. Pairwise matching to a cohort undergoing RC during an earlier era of more liberal PBT was performed, and 90-day outcomes were compared.Results: Median follow-up for the RTP cohort was 3.1 years (range: 0-5.1 y). Median age was 70 years (range: 38-93 y). Forty-six patients (26.6%) received PBT. Eighty-seven matched pairs were generated from RTP cohort and liberal era where PBT rate was 94%. There were no differences in 90-day complication rates, mortality, or readmission rates (P > 0.05). In the RTP cohort, patients who underwent PBT had higher estimated blood loss (500 vs. 350, P = 0.001), lower baseline hematocrit (28.9 vs. 33.3, P = 0.005), and similar operative time (5.8 vs. 5.3 h, P = 0.01) and length of stay (5.5 vs. 5, P = 0.07). At discharge and 3-week follow-up, there was no difference in hematocrit (P > 0.05). In the no-PBT group, 90-day (65.6% vs. 86.7%, P = 0.007) and high-grade (15.6% vs. 34.8%, P = 0.003) complication rates were lower. On multivariable analysis, predictors of PBT were age (odds ratio [OR] = 1.06, 95% CI [1.01-1.11]), Charlson comorbidity index >= 2 (OR = 2.68, CI [1.09-7.04]), neoadjuvant chemotherapy (OR = 3.74, CI [1.46-10.19]), >= pT3 (OR = 5.5, CI [2.33-13.73]), baseline hematocrit (OR = 0.95, CI [0.87-1.00]), and estimated blood loss (OR = 1.001, CI [1-1.003]). PBT was associated with lower recurrence-free survival (hazard ratio = 2.16; CI [1.13-41.12]; P = 0.02) and overall survival (hazard ratio = 2.25; CI [1.25-4.88]; P = 0.01).Conclusions: The use of RTP in RC is safe. PBT was associated with poorer recurrence-free survival and overall survival independent of clinicopathologic characteristics. (C) 2017 Elsevier Inc. All rights reserved.

You have accessJournal of UrologySurgical Technology & Simulation: Training & Skills Assessment II1 Apr 2016MP20-10 STRUCTURED LEARNING FOR ROBOTIC SURGERY UTILIZING A GENERIC PROFICIENCY SCORE Andrew J. Hung, Thomas Bottyan, Sarfaraz Serang, Thomas G. Clifford, Swar H. Shah, Hana Yokoi, Monish Aron, and Inderbir S. Gill Andrew J. HungAndrew J. Hung More articles by this author , Thomas BottyanThomas Bottyan More articles by this author , Sarfaraz SerangSarfaraz Serang More articles by this author , Thomas G. CliffordThomas G. Clifford More articles by this author , Swar H. ShahSwar H. Shah More articles by this author , Hana YokoiHana Yokoi More articles by this author , Monish AronMonish Aron More articles by this author , and Inderbir S. GillInderbir S. Gill More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2779AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We evaluated feasibility and benefit of implementing structured learning in a high volume robotics program. Furthermore, we assessed validity of a proficiency assessment tool for step-wise graduation. METHODS Teaching cases included robotic radical prostatectomy and partial nephrectomy. Procedure steps were prospectively categorized by robotic expert consensus as: basic, intermediate, advanced. Experts also developed an assessment tool (“Proficiency Score” (PS)) to evaluate ability to safely and autonomously complete a step. A customized web application for smart phones was developed to facilitate survey distribution and data capture. A screenshot of the PS assessment tool on an iPhone is shown (Figure). Graduation of a surgical step required a passing PS (PS≥3) on three consecutive attempts. The PS and validated Global Evaluative Assessment of Robotic Skills (GEARS) were evaluated for completed steps. Linear regression was utilized to determine post-graduate year/PS relationship (construct validity). Spearman's rank correlation coefficient measured correlation between PS and GEARS evaluations (concurrent validity). Intraclass correlation (ICC) evaluated PS agreement between evaluator class. Paired T-tests evaluated change in the percent of cases for which trainees received expert feedback. RESULTS Thirteen robotic trainees participated, completing a median of 10 (2-39) cases each. The 18 study evaluators scored 11 (2-34) cases. Over four months, 121/165 (74%) cases were designated as “teaching” cases. Residents completed 94% of possible evaluations while faculty completed 79%. Verbal and quantitative feedback received by trainees increased significantly (p=0.002, p<0.001, respectively). Average PS increased with PGY for basic and intermediate steps (regression slopes: 0.461 (p<0.0001), 0.428 (p<0.0005), respectively) (construct validation). Overall, PS correlated highly with GEARS (ρ=0.81, p<0.0001) (concurrent validity). ICC was 0.79 (95% CI 0.60-0.90) for resident evaluations. CONCLUSIONS Structured learning can be implemented in an academic robotic program with high levels of trainee and evaluator participation, encouraging both quantitative and verbal feedback. A proficiency assessment tool developed for step-specific proficiency has construct and concurrent validity. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e216 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Andrew J. Hung More articles by this author Thomas Bottyan More articles by this author Sarfaraz Serang More articles by this author Thomas G. Clifford More articles by this author Swar H. Shah More articles by this author Hana Yokoi More articles by this author Monish Aron More articles by this author Inderbir S. Gill More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Experienced surgeons commonly mentor trainees as they move through their initial learning curves. During robot-assisted minimally invasive surgery, several tools exist to facilitate proctored cases, such as two-dimensional telestration and a dual surgeon console. The purpose of this study was to evaluate the utility and efficiency of three, novel proctoring tools for robot-assisted minimally invasive surgery, and to compare them to existing proctoring tools. Twenty-six proctor-trainee pairs completed validated, dry-lab training exercises using standard two-dimensional telestration and three, new three-dimensional proctoring tools called ghost tools. During each exercise, proctors mentored trainees by correcting trainee technical errors. Proctors and trainees completed post-study questionnaires to compare the effectiveness of the proctoring tools. Proctors and trainees consistently rated the ghost tools as effective proctoring tools. Both proctors and trainees preferred 3DInstruments and 3DHands over standard two-dimensional telestration (proctors p < 0.001 and p = 0.03, respectively, and trainees p < 0.001 and p = 0.002, respectively). In addition, proctors preferred three-dimensional vision of the operative field (used with ghost tools) over two-dimensional vision (p < 0.001). Total mentoring time and number of instructions provided by the proctor were comparable between all proctoring tools (p > 0.05). In summary, ghost tools and three-dimensional vision were preferred over standard two-dimensional telestration and two-dimensional vision, respectively, by both proctors and trainees. Proctoring tools—such as ghost tools—have the potential to improve surgeon training by enabling new interactions between a proctor and trainee.

Purpose: Hernia is a common complication following radical cystectomy and urinary diversion. We investigated the clinical and radiological evidence for parastomal and incisional hernias, and their risk factors in a large cohort.Materials and Methods: Using an institutional review board approved prospective database we reviewed the records of 1,101 patients who underwent radical cystectomy from 2003 to 2013. Followup (median 57 months) was available for 670 patients. Of the 670 patients 92 underwent ileal conduit diversion using Turnbull stomas with a median followup 34 months. Patients were followed with computerized tomography cancer surveillance. Standardized criteria were used to define parastomal and incisional hernias by an expert radiologist. Multivariate logistic regression was done to identify independent predictors.Results: Parastomal hernia was diagnosed in 21 of 92 patients (23%) with a mean age at diagnosis of 76.5 years. Incisional hernia was present in 125 of 670 patients (18.7%) with a mean age at diagnosis of 68.6 years. Five patients had both hernia types. Of patients with parastomal and incisional hernias 11 (53%) and 111 (88.8%), respectively, were male. Mean body mass index was 27.5 and 27.3 kg/m(2) in patients with parastomal and incisional hernias, respectively. Mean parastomal and incisional defect sizes were 3.8 and 2.4 cm, respectively. In 18 patients (85%) parastomal hernias were clinically and radiologically evident, 5 patients were symptomatic and 2 underwent repair. In 51 patients (40%) incisional hernias were clinically and radiologically evident, 34 were symptomatic and 48 underwent repair. Multivariate logistic regression showed significant associations of incisional hernia with age, gender, incision length, orthotopic diversion and body mass index. Parastomal hernia had no significant association.Conclusions: Hernia is common after cystectomy and diversion. Age, gender, body mass index, incision length and diversion type are risk factors for incisional hernia. Multi-institutional prospective studies may better identify patients at high risk.

We evaluated feasibility and benefit of implementing structured learning in a robotics program. Furthermore, we assessed validity of a proficiency assessment tool for stepwise graduation.

Purpose: We evaluated continence outcomes in male patients undergoing orthotopic neobladder diversion after radical cystectomy using a validated questionnaire.Materials and Methods: Using our institutional review board approved bladder cancer database we identified 1,269 patients who underwent open radical cystectomy from 2002 to 2015. Orthotopic neobladder was constructed in 935 (74%) patients, of whom 798 (85%) were male. Beginning in 2012 the patients completed a validated pictorial pad use questionnaire at each followup visit. The questionnaire assessed pad number, size and wetness as well as catheter use. Continence was defined as use of no pads or pads that are almost dry. Questionnaires were stratified into distinct postoperative intervals for analysis. Female patients, or patients with artificial urinary sphincters or prior radiotherapy were excluded from the study.Results: A total of 188 male patients with available questionnaires were followed from September 2012 to August 2015. Overall 447 questionnaires were collected, with 351 interval distinct questionnaires separated into intervals of less than 3, 3 to 6, more than 6 to 12, more than 12 to 18, more than 18 to 36 and more than 36 months after surgery (64, 61, 58, 49, 61 and 58 questionnaires, respectively). Daytime continence increased from 59% at less than 3 months postoperatively to 92% by more than 12 to 18 months. Nighttime continence increased from 28% at less than 3 months postoperatively to 51% by more than 18 to 36 months. Nearly 50% of patients reported daytime and nighttime continence by 18 to 36 months.Conclusions: After orthotopic neobladder diversion in male patients, continence improves significantly by 6 months and subsequently plateaus with 92% daytime continence by more than 12 to 18 months. Orthotopic neobladder represents an excellent functional option for urinary diversion.

You have accessJournal of UrologyProstate Cancer: Detection and Screening VII1 Apr 2015MP86-17 CLINICALLY SIGNIFICANT INCIDENTAL PROSTATE CANCER DETECTED IN RADICAL CYSTOPROSTATECTOMY SPECIMENS Swar Shah, Soroush Bazaragani, Gus Miranda, Hooman Djaladat, Anne Schuckman, and Siamak Daneshmand Swar ShahSwar Shah More articles by this author , Soroush BazaraganiSoroush Bazaragani More articles by this author , Gus MirandaGus Miranda More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1926AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While the focus of radical cystoprostatectomy (RC) is usually a bladder-primary malignancy, incidental prostate cancer is a common finding during pathological examination of the surgical specimen. While mostly clinically insignificant and generally minimally monitored, we sought to characterize clinically significant prostate cancer (csPCA), which may require closer monitoring. Herein, we evaluate the role of prostate specific antigen (PSA) in monitoring csPCA diagnosed at the time of RC. METHODS Using and IRB approved prospective database, we identified 1451 patients who underwent RC between 2003 and 2014 at our institution. Clinically significant prostate cancer was defined as Gleason score ≥7, extra prostatic extension, seminal vesicle involvement, positive surgical margin, and lymph node involvement. PSA values were recorded. In patients with evidence of a biochemical recurrence, complete follow up was obtained. Patients were diagnosed with recurrence based on PSA values or findings on cross sectional imaging. RESULTS We identified a total of 107 patients with csPCA diagnosed at the time of RC, of whom 42 had PSA followup. Average age at the time of RC in these patients was 72.24 ± 9.52 years, with a median follow up of 2.18 years. Mean baseline PSA prior to surgery was 4.45±7.49. Two (4.7%) patients developed a recurrence of their prostate cancer, aged 66 and 65 at the time of surgery, and diagnosed 6.8 and 6.1 years after RC. Both had Gleason grade 3+4 on RC pathology, with no capsule penetration, bladder extension, seminal vesicle involvement, or nodal extension. PSA at the time of recurrence was 0.12 and 43.6 each. PSA peaks were 0.52 and 80.6, respectively. The first was diagnosed based on an enlarged lymph node on routine postoperative cross sectional imaging followed by a steady rise in PSA, which was ultimately biopsy proven PCA. He was unable to undergo radiotherapy because his neobladder would not tolerate the doses of radiation required for prostate cancer and refused ADT. The second was diagnosed based on a markedly elevated PSA, and underwent ADT with a normalization of his markers. He had a marker relapse 3 years after cessation of ADT. Both were alive at last follow up, 6.9 and 9.5 years post-surgery. CONCLUSIONS Less than 5% of patients develop a relapse after diagnosis of csPCA on RC pathology. The relative paucity of recurrence makes it difficult to establish parameters for monitoring, however time to diagnosis (>6 years) suggests long term-follow up in these patients may be necessary to monitor for recurrence. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1082 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Swar Shah More articles by this author Soroush Bazaragani More articles by this author Gus Miranda More articles by this author Hooman Djaladat More articles by this author Anne Schuckman More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion I1 Apr 2015PD9-01 CONTINENCE OUTCOMES FOLLOWING RADICAL CYSTECTOMY AND ORTHOTOPIC NEOBLADDER Swar Shah, Soroush Bazaragani, Gus Miranda, Kevin Wayne, Hooman Djaladat, Anne Schuckman, and Siamak Daneshmand Swar ShahSwar Shah More articles by this author , Soroush BazaraganiSoroush Bazaragani More articles by this author , Gus MirandaGus Miranda More articles by this author , Kevin WayneKevin Wayne More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.928AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Orthotopic neobladder reconstruction arguably represents the gold standard form of urinary diversion following radical cystectomy. However, no contemporary continence information is available. Herein, we evaluate the continence outcomes in patients undergoing orthotopic neobladder following radical cystectomy using a validated pad usage questionnaire. METHODS Using our IRB approved database, we identified 1545 patients that underwent open radical cystectomy from 2000 to 2014. Orthotopic neobladder was constructed in 1057 (68%) patients, of whom 892 (84%) were male. Starting in 2012, these patients were prospectively followed, and completed a validated, pictorial pad usage questionnaire during their follow up visits assessing the number, size, and wetness of pads, and mucus leakage. Continence was defined as reporting no pad usage, or pads as “almost dry,” and questionnaires were stratified into distinct postoperative time intervals. For patients who completed multiple questionnaires within an interval, the most recent was used in the analysis. Patients with artificial urinary sphincters or a history of radiation therapy were excluded. RESULTS A total of 180 male patients with available pad usage questionnaires were followed from August 2012 to October 2014. A total of 284 pad usage questionnaires were collected, with 243 interval distinct pad usage questionnaires identified and separated into intervals of < 3 months, 3–6 months, 6–12 months, 12–18 months, 18–36 months, and more than 36 months after surgery (n= 42, 39, 41, 34, 45, and 42, respectively). Daytime continence rates were 55%, 69%, 78%, 88%, 87%, and 81%, respectively. The corresponding numbers for nighttime continence rates were 26%, 38%, 46%, 44%, 58%, and 45%, respectively. In the 18–36 month range, 53% of patients reported both day and nighttime continence. CONCLUSIONS Following orthotopic urinary diversion, there is significant improvement in continence by 6 months, and 88% of patients achieved daytime continence by 12 months. There is a plateau in continence rates at one year. Orthotopic diversion represents an excellent functional option for urinary diversion. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e195 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Swar Shah More articles by this author Soroush Bazaragani More articles by this author Gus Miranda More articles by this author Kevin Wayne More articles by this author Hooman Djaladat More articles by this author Anne Schuckman More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

You have accessJournal of UrologyTechnology & Instruments: Surgical Education & Skills Assessment II1 Apr 2015MP23-15 COMPARATIVE EVALUATION OF 2D AND NOVEL 3D ROBOTIC SURGERY MENTORING TOOLS Swar Shah, Anthony Jarc, Eric Hwang, Joey Chau, Jean-Christophe Bernhard, Inderbir Gill, Monish Aron, and Andrew Hung Swar ShahSwar Shah More articles by this author , Anthony JarcAnthony Jarc More articles by this author , Eric HwangEric Hwang More articles by this author , Joey ChauJoey Chau More articles by this author , Jean-Christophe BernhardJean-Christophe Bernhard More articles by this author , Inderbir GillInderbir Gill More articles by this author , Monish AronMonish Aron More articles by this author , and Andrew HungAndrew Hung More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1258AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The gold standard of robotic surgery mentoring is in-room proctoring via telestration on the vision cart touchscreen or 3D cursors on a second console. Previous investigation of remote tele-mentoring on the da Vinci® Si was limited to bi-directional audio with 2D vision and telestration for the proctor. Herein, we present an initial evaluation of the utility and efficiency of three novel 3D proctoring tools compared to standard 2D telestration. METHODS Pre-study questionnaires classified participants as trainees (<50 robotic cases, n=16) or proctors (≥50 robotic cases or Intuitive Surgical standardized proctors, n=16). Proctors mentored trainees using 4 tool types: 2D telestration, 3D pointers, 3D hands, and 3D instruments (Figure) – all with bi-directional audio. Proctor tool was randomly ordered and paired with one of 4 validated dry lab tasks. For each task, temporal metrics and number of errors committed were recorded. Proctors and trainees completed post exercise and post study questionnaires. Median and range of responses were calculated. Mann-Whitney U and Kruskal-Wallis tests were used for pairwise and group comparisons of proctor tools, respectively. RESULTS Overall, 80% of proctors favored mentoring with 3D vision to 2D vision (median 4.5/5). Proctors found 3D instruments more effective than 2D telestration and 3D pointers, and no different than 3D hands (p = 0.03, 0.05, 0.3, respectively). Trainees found 3D instruments more effective than 2D telestration and 3D pointers (p=0.001 and 0.009, respectively). Trainees also found 3D hands more effective than 2D telestration and 3D pointers (p=0.01 and 0.03, respectively), and reported no difference between 3D hands and 3D instruments (p=0.3). Though not significant, mean number of errors identified and mentored per tool type shows an increasing trend with tool complexity from 2D telestration, 3D pointers, 3D hands, to 3D instruments (p>0.05). No significant difference was detected for total number of errors, mean mentor time per error or time mentored per tool (p>0.05). CONCLUSIONS Experts preferred 3D vision for robotic mentoring, particularly with 3D instruments. More sophisticated mentoring tools, such as these, may enable mentors to better train new robotic surgeons by identifying more trainee errors and by providing more efficient and meaningful instruction. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e272-e273 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Swar Shah More articles by this author Anthony Jarc More articles by this author Eric Hwang More articles by this author Joey Chau More articles by this author Jean-Christophe Bernhard More articles by this author Inderbir Gill More articles by this author Monish Aron More articles by this author Andrew Hung More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

You have accessJournal of UrologyBladder Cancer: Detection and Screening I1 Apr 2015PD23-09 EPITHELIAL TUMOR MARKERS (CA 125, CA 19-9 AND CEA) TRENDS IN PATIENTS UNDERGOING TREATMENT FOR INVASIVE BLADDER CANCER Soroush T. Bazargani, Swar Shah, Hamed Ahmadi, Anne Schuckman, Jie Cai, Gus Miranda, Tanya Dorff, Sarmad Sadeghi, David Quinn, Hooman Djaladat, and Siamak Daneshmand Soroush T. BazarganiSoroush T. Bazargani More articles by this author , Swar ShahSwar Shah More articles by this author , Hamed AhmadiHamed Ahmadi More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , Jie CaiJie Cai More articles by this author , Gus MirandaGus Miranda More articles by this author , Tanya DorffTanya Dorff More articles by this author , Sarmad SadeghiSarmad Sadeghi More articles by this author , David QuinnDavid Quinn More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1425AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Epithelial tumor markers, like CA 125, CA 19-9 and CEA have been associated with worse oncological outcomes in patients with invasive bladder cancer (BC). Herein, we report marker response to treatment and their association with oncological outcomes. METHODS Using our IRB approved BC database, we identified 252 patients who had available CA 125, CA 19-9, and CEA levels before and after cystectomy for urothelial BC. Patients undergoing neoadjuvant chemotherapy (NAChT) had tumor makers measured prior to the first and after the last cycle of chemotherapy (before cystectomy). Patients were followed closely and marker levels were checked on each visit in those with elevated pre-cystectomy markers, and at the time of relapse in others. RESULTS A total of 202 patients (mean age at cystectomy 70, 78% male) with available markers at follow-up were included in the study. 26 patients had complete tumor marker profile before and after NAChT. 12/26 had one or more elevated tumor markers prior to NAChT. After completing chemotherapy, 7/12 (58%) had normalized tumor markers. Of the 5 (42%) patients who still had elevated levels, 4 died (3 cancer-related) at a median of 5 months, compared to only 1 death in the group with normalized markers following NAChT. Of those who underwent cystectomy only, 139 (69%) patients had normal markers while 63 (31%) had at least one abnormal pre-cystectomy marker. Cox Regression models showed the risk of recurrence was 4 times higher, with at least one elevated tumor marker (p=0.001) with a hazard ratio for death of 19.7 (p<0.0001) (Figures 1, 2). Elevated pre-cystectomy levels of CA19-9 and CA125 were associated with recurrence (p<0.01), and elevated levels of each of the three markers prior to cystectomy were strongly predictive of mortality (p <0.002). CONCLUSIONS The study confirms the predictive role of these three epithelial tumor markers for mortality and the association of CA125 and CA 19-9 with recurrence in invasive bladder cancer. Patients with persistently elevated markers postoperatively have a poor prognosis. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e483-e484 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Soroush T. Bazargani More articles by this author Swar Shah More articles by this author Hamed Ahmadi More articles by this author Anne Schuckman More articles by this author Jie Cai More articles by this author Gus Miranda More articles by this author Tanya Dorff More articles by this author Sarmad Sadeghi More articles by this author David Quinn More articles by this author Hooman Djaladat More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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.

You have accessJournal of UrologyTechnology & Instruments: Surgical Education & Skills Assessment II1 Apr 2015MP23-08 INITIAL VALIDATION DURING DEVELOPMENT OF LOW COST ALTERNATIVE TO THE DV-TRAINER USING THE HYDRA SYSTEM Swar Shah, Eric Hwang, Inderbir Gill, and Andrew Hung Swar ShahSwar Shah More articles by this author , Eric HwangEric Hwang More articles by this author , Inderbir GillInderbir Gill More articles by this author , and Andrew HungAndrew Hung More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1251AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic simulation is a popular training modality. However, simulators are costly, driving a push for lower cost options to improve access to training. Herein, we evaluate the face, content, and construct validity of a proof-of-concept simulation platform developed by Mimic Technologies, Inc. using third party, off-the-shelf gaming controllers (Hydra System) on existing virtual (VR) and procedure-specific augmented reality (AR) and procedure-specific VR (PS VR) exercises previously validated on the dV-Trainer (dVT). METHODS Participants were classified as novice (no robot experience, n=21) or expert (≥30 console cases, n=9) and prospectively assessed on a VR suturing task, robotic partial nephrectomy procedure-specific AR module, and PS VR suturing task on both the Hydra and dVT platforms. Post exercise and post study questionnaires assessed realism of simulation (face validity) and utility for training (content validity), as well as user feedback for each system via Likert scale. Integrated tasks and questions in the AR module were assessed. Questionnaire responses, as well as novice and expert performance data, were compared using t tests to establish face, content, and construct validity. RESULTS Face Validity: Experts rated Hydra “very realistic” on the AR module (4/5 (2-5)), but less so for VR and PS VR tasks. VR on Hydra was significantly less realistic than dVT (p=0.02), with no difference in PS VR and AR. Content Validity: On the AR module, Hydra had content validity for training residents, and teaching anatomy and operation steps (4-5/5). The Hydra VR and PS VR tasks had lower content validity, with the VR task rating significantly less for training residents and teaching technical skills (p=0.01 and 0.005, respectively). Construct Validity: For the VR task construct validity was seen in 4 of 7 metrics (p ≤ 0.03) on Hydra and 6 of 7 metrics (p ≤0.04) on dVT. Hydra did not show construct validity in the AR module and PS VR task. User Feedback: Hydra was rated “moderately” easy, comfortable, and smooth to use (3/5 (1-4) each). The interface was rated “fair” (2/5 (1-3)), versus “very good” for dVT (4/5 (3-5), p= <0.0001). CONCLUSIONS This proof-of-concept, low-cost prototype based on the Hydra System for robotic simulation demonstrates face and content validity in an AR module for teaching residents cognitive content (anatomy and steps). The prototype has construct validity presently limited to VR basic skills tasks. This data is valuable for defining platform refinements, and highlights the role of early validation during simulation development. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e270 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Swar Shah More articles by this author Eric Hwang More articles by this author Inderbir Gill More articles by this author Andrew Hung More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

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.

Radiation and chemotherapy for seminoma are associated with significant long-term morbidity. We identified 4 patients with lymph node-positive seminoma who had been treated with front-line retroperitoneal lymph node dissection (RPLND). No patient had experienced disease recurrence at a mean follow-up period of > 2 years. A phase II trial is planned to evaluate the efficacy of RPLND for seminoma.Introduction: The long-term morbidity associated with treating advanced seminoma can be significant. Retroperitoneal lymph node dissection (RPLND) has established oncologic efficacy in treating germ cell tumors with minimal long-term toxicity. We describe our experience with RPLND as a front-line treatment of lymph node-positive seminoma. Materials and Methods: We reviewed our institutional review board-approved testicular cancer database to find the patients with pure seminoma and isolated retroperitoneal lymph node disease who had undergone primary RPLND. The clinical and pathologic variables were obtained. The follow-up data were used to determine recurrence and death. Results: Four patients with a mean age of 37 years were identified. All patients had normal tumor markers and retroperitoneal lymphadenopathy measuring 1.1, 1.5, 1.8, and 5.5 cm before RPLND. Of the 4 patients, 3 had had seminoma diagnosed at orchiectomy and 1 (with a 5.5-cm retroperitoneal lymphadenopathy and a burned out primary testicular mass) had had seminoma diagnosed at RPLND after 2 nondiagnostic retroperitoneal biopsies. All patients had undergone nerve-sparing, template, extraperitoneal RPLND and were discharged home after 3 days. An average of 3 positive lymph nodes were found. Of the 4 patients, 3 had pathologic stage IIA and 1 stage IIB disease, with no patient undergoing adjuvant therapy. At a mean follow-up period of 25 months, no patient had experienced disease recurrence, and none had died. All patients maintained antegrade ejaculation, and no long-term complications had developed. Conclusion: Our small series has demonstrated encouraging oncologic efficacy for RPLND as a primary treatment of retroperitoneal lymph node-positive seminoma. A multi-institutional phase II trial of RPLND for stage IIA seminoma is being developed. (C) 2015 Elsevier Inc. All rights reserved.