Friday, May 16, 2014 1:00 PM-3:00 PM
OCCC: W 311 C
Funding: none
PD1-06: Contemporary Minimally Invasive Management of Adrenal Disorders: An International Multi-Institutional Survey 
Hak Lee*, Ithaar Derweesh, Song Wang, Ramzi Jabaji, Kyle Gilis, La Jolla, CA, Riccardo Autorino, Luis Brandao, S. Jeff Chueh, Jihad Kaouk, Cleveland, OH, Yinghao Sun, Bo Yang, Guo Fei, Shanghai, China, People’s Republic of, Deok Hyun, Byong Chang Jeong, Seoul, Korea, Republic of, Francesco Greco, Vincenzo Altieri, Rocca di Neto, Italy, Paolo Fornara, Halle Saale, Germany, Luca Cindolo, Francesco Berardinelli, Luigi Schips, Vasto, Italy, Christian Fiori, Francesco Porpiglia, Orbassano, Italy, Xiang Chen, Zhi Chen, Yao He, Changsha, China, People’s Republic of, Anibal Branco, Curitiba, Brazil, Chun-Hou Liao, Taipei, Taiwan, Iason Kyriazis, Evangelos Liatsikos, Patra, Greece, Akira Miyajima, Mototsugu Oya, Tokyo, Japan

Abstract: PD1-06
Introduction and Objectives
Over the past 20 years, as surgeons have become more technically proficient and comfortable with different minimally invasive techniques, there has been a shift in the surgical management of adrenal lesions. From open to multi-port conventional laparoscopy, robotics and Laparo-Endoscopic Single-Site (LESS) surgery; urologists now have an armamentarium of surgical techniques to manage adrenal masses. In this study, we evaluated the current international trends in the surgical management of adrenal masses.Methods
A retrospective international multi-center study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013. Twelve international academic centers were included in the analysis and patients were categorized by different minimally invasive treatments for adrenalectomy: conventional laparoscopy (CL), robotics, LESS and mini-lap (ML). The rates of the four treatment modalities were determined according to year of surgery. A regression analysis was performed for trends in all surgical modalities.Results
Overall, a total of 885 adrenalectomies were performed from all centers. A total of 358 (31%) of CL, 193 (22%) of ML, 269 of LESS (30%) and 65 (7%) of robotic adrenalectomy were performed across all institutions. The overall number of adrenalectomies have increased from 2008-2013, p=0.02 (Figure). The overall utilization of CL and LESS has been steadily increasing and the fastest growing. However, the proportion of CL in all adrenalectomies from 2008 to 2013 had decreased from 100% to 39%, respectively. Whereas, LESS, ML, and robotics had increased from 0 to 9%, 13% and 39% respectively. From 2008 to 2013, LESS had the fastest increase in utilization at 6.5%/yr. The rate of robotic adrenalectomies started to increase from 2009, but at slow rates (1.5%/yr), similar to ML (2.2%/yr). Overall, CL and LESS are the most widely utilized modalities, and robotics and ML are far behind in utilization for adrenalectomies.Conclusions
Over time, we noted an increase of adrenalectomies from all modalities. CL and LESS are the most commonly utilized technique, whereas ML and robotics has been slower in growth. Further investigation is necessary to understand the driving forces behind these trends.Date & Time: May 16, 2014 1:00 PM-3:00 PM
Session Title: Adrenal
Sources of Funding: none


Friday, May 16, 2014 1:00 PM-3:00 PM
OCCC: W 311 C
Funding: None.
Brett Parker, Michael Degen, Ravi Munver*, Hackensack, NJ

Abstract: PD1-07
Introduction and Objectives
Robotic adrenalectomy (RA) is gaining popularity relative to the more established laparoscopic approach. We compared our experience with robotic and laparoscopic adrenalectomy (LA) techniques and evaluated perioperative variables, outcomes, and complications.Methods
A total of 63 consecutive procedures were evaluated since 2003. Eleven RA and 11 LA were evaluated, of which 3 and 3 were partial adrenalectomy procedures respectively. All cases were performed by a single surgeon in a tertiary care medical center. Data was prospectively collected and maintained in a database that was routinely updated. All parameters were analyzed using the Student t-test and described as the mean ± standard deviation.Results
The age, gender, and BMI were statistically similar between the RA and LA cohorts (Table 1). Tumor pathology amongst the two groups is described per Table 2. The average tumor size for RA was 4.2 +/- 2 cm (1.5 – 6.8) and 3.3 +/- 1.6 cm (0.4 – 7.2) for LA. Total operating time was similar between RA (157 +/- 29 [105-210]) and LA (159 +/- 57 [80-288]). The estimated blood loss was statistically similar with RA (58 mL +/- 39 [10-100]) versus LA (43mL +/- 51 [5-100]). With LA, major complications included one incident of intraoperative adrenal vein bleeding/hemorrhage and one episode of transient hand parasthesia. In the RA group there was one incident of intraoperative bleeding/hemorrhage secondary to preoperative antiplatelet therapy. There were no conversions to open surgery and no mortality.Conclusions
Robotic adrenal surgery is an evolving procedure that is safe effective and comparable to laparoscopic adrenalectomy. The distinct advantages of robotics are not acutely evident from the results of this study. Surgeon preference and experience, along with cost, must be considered when choosing between the two approaches.Date & Time: May 16, 2014 1:00 PM-3:00 PM
Session Title: Adrenal
Sources of Funding: None.

Gender (M:F) Age (yrs) BMI (kg/m2)
Robot-assisted adrenal surgery 5:6 54 +/- 16 (17-73) 28 +/- 6 (20-40)
Laparoscopic adrenal surgery 5:6 52 +/-14 (25-82) 30 +/- 7 (19-49)
Robot-Assisted Adrenal Surgery (n=11) Laparoscopic Adrenal Surgery (n=11)
Cortical adenoma 7 7
Pheochromocytoma 2 2
Benign epithelial/hemorrhagic cyst 1 1
Carcinoma 1 1


Friday, May 16, 2014 1:00 PM-3:00 PM
OCCC: W 311 G
General & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes I
Funding: This work was supported by funding from the National Cancer Institute, the Agency of Healthcare Research and Quality, and the Life Sciences Discovery Fund.
PD2-02: Quality Improvement Opportunities in Prostatectomy Care in a Regional Hospital-Based Urologic Quality Collaborative 
John L. Gore*, Michael Porter, John Corman, Seattle, WA, Douglas Sutherland, Tacoma, WA, Zeila Schmidt, David Flum, Seattle, WA

Abstract: PD2-02
Introduction and Objectives
Prostate cancer care is susceptible to regional variation in selection for treatment and outcomes after primary therapy. Recent national recommendations have highlighted the harms of prostate cancer treatment including urinary incontinence and erectile dysfunction. We prospectively evaluated radical prostatectomy (RP) outcomes at participating Washington-state hospitals to identify quality improvement opportunities in RP care.Methods
We convened a clinician advisory group of local urologists engaged in prostate cancer care to develop a chart abstraction tool that captures potential quality concerns in RP care. The abstraction tool was implemented at nine regional hospitals with data consolidated for review quarterly. The research team and clinician advisory group were blinded to the hospital identities in hospital-specific feedback reports. Data were analyzed as aggregate rates and hospital-specific rates without risk adjustment using descriptive statistics.Results
We abstracted data on 461 patients undergoing RP at 9 area hospitals from 2011-2013. The majority were robot-assisted minimally invasive RPs (344/461, 74%), Participating hospitals report as many as 97% or as few as 12% robot-assisted procedures. 26.3% of cases were pathologic non-organ-confined prostate cancer (pT3 or higher); pathologic stage was not further classified beyond “T2” or “T3” in 31% of RPs. Surgical margins were positive in 18% of cases overall; hospital-specific positive margin rates ranged from 12-25% among organ-confined cases and 0-75% among stage pT3 or higher prostate cancer. Lymphadenectomy was performed in 53-100% of RPs by hospital for intermediate and high-risk cancer cases. Length of stay exceeded three days post-prostatectomy in more than 10% of cases at 4 hospitals including one hospital where 36% of cases had prolonged lengths of stay.Conclusions
We identified several quality improvement opportunities that may improve health outcomes among men undergoing RP for prostate cancer. Positive margin rates were excessive at some hospitals and may represent uncertainty in the surgical approach to higher risk cases. Variation in lengths of stay may represent provider variation in post-prostatectomy clinical care algorithms. Survey of provider practices may inform development of quality improvement initiatives such as clinical pathways that may address the variations in RP care identified.Date & Time: May 16, 2014 1:00 PM-3:00 PM
Session Title: General & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes I
Sources of Funding: This work was supported by funding from the National Cancer Institute, the Agency of Healthcare Research and Quality, and the Life Sciences Discovery Fund.


Friday, May 16, 2014 1:00 PM-3:00 PM
OCCC: W 311 G
General & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes I
Funding: None
PD2-04: Surgeon Adoption of Minimally Invasive Radical Prostatectomy 
Christopher Anderson*, Coral Atoria, Karim Touijer, James Eastham, Elena Elkin, New York, NY

Abstract: PD2-04
Introduction and Objectives
Minimally invasive radical prostatectomy (MIRP) is now the most common surgical treatment for prostate cancer, and many open surgeons have adopted the minimally invasive approach. Our objective was to describe the pattern of MIRP adoption among surgeons, and assess whether open surgeons who adopted MIRP had inferior outcomes to surgeons who exclusively performed MIRP.Methods
In the population-based SEER-Medicare dataset, we identified all surgeons who performed MIRP or open radical prostatectomy (ORP) for prostate cancer from 2002-2008. Minimally invasive surgeons were classified as converters if they had performed ORP prior to their first MIRP, or de novo if they had not. We calculated the proportion of prostatectomies converters performed minimally invasively each year. In a cohort of men ≥66 years old who had MIRP for prostate cancer from 2003-2008, we used logistic regression to estimate the impact of surgeon type (converter vs. de novo) on the receipt of any secondary cancer treatment, and claims for incontinence, erectile dysfunction (ED) and bladder outlet obstruction (BOO) at ≥3 months postoperatively. All endpoints were assessed at 3 years postoperatively.Results
We identified 750 MIRP surgeons (450 converters and 300 de novo) who performed 9,193 MIRPs. On average there were 75 (SD 30) new converters and 50 (SD 23) new de novo surgeons each year. Converters performed 65% of all MIRPs and de novo surgeons performed 35%, although their average annual MIRP volume was similar (converter 5.3 (SD 6.8) vs. de novo 5.5 (SD 12.3)). In 2003 converters performed a median 50% (IQR 33.3%, 95.5%) of their cases minimally invasively which increased to 100% (IQR 83%, 100%) in 2008 (figure). At 3 years after surgery, there were no differences in use of secondary cancer treatments (OR 1.09 [95% CI 0.71-1.69]), and incontinence (OR 1.21 [95% CI 0.87-1.69]) or BOO (OR 1.01 [95% CI 0.69-1.47]) between patients treated by converters and de novosurgeons, controlling for patient characteristics and surgeon MIRP volume. However, patients treated by converters had a higher rate of ED (OR 1.48 [95% CI 1.11-1.98]).Conclusions
Following the introduction of robotic technology many open surgeons rapidly adopted MIRP. Converters may have had a different intensity of MIRP training than de novo surgeons, translating to variations in their patients’ functional outcomes.Date & Time: May 16, 2014 1:00 PM-3:00 PM
Session Title: General & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes I
Sources of Funding: None


Friday, May 16, 2014 3:30 PM-5:30 PM
OCCC: W 314
General & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes II
Funding: None
MP2-06: Can prognostic nutritional index (PNI) predict outcomes after Robot-assisted Radical Cystectomy? 
Mohammed Tawfeeq, Syed Johar Raza, Katherine Szymanski*, Ali Al-Daghmin, Erinn Field, Zayn Mehboob, Andrew Syposs, Zhengyu Yang, Katy Wang, Gregory Wilding, Buffalo, NY, Khurshid Guru, East Amherst, NY

Abstract: MP2-06
Introduction and Objectives
Nutritional status plays an important role in the outcomes of malignant diseases. Prognostic Nutritional Index (PNI) has been successfully used to predict outcomes in colo-rectal cancer, however no reports exist for its use in bladder cancer. This study aims to determine if PNI can predict the operative and oncological outcomes following robot-assisted radical cystectomy (RARC) in bladder cancer.Methods
A retrospective comparative analysis of patients undergoing RARC was performed. PNI was measured using the serum albumin and absolute lymphocyte counts (PNI= Albumin x 10 + LC x 0.005). Based on the preoperative PNI values, all patients were divided into 2 groups, (PNI > 50 – normal and < 50 – malnutrition). Both groups were compared in terms of their baseline (demographic and clinical) outcomes. Oncologic and peri-operative outcomes included complications, hospitalization (stay and readmissions) were evaluated. Multivariable analysis was performed to determine if PNI score affected the operative or oncological outcomes.Results
203 patients had their PNI determined using the mentioned formula. Mean age was 68.3 years (+/-10.8). Seventy two patients were categorized as PNI > 50, while 131 belonged to PNI <50. Both groups were comparable in age, gender, BMI, duration of surgery, estimated blood loss and pathological T stage. The mean ASA score was significantly lower in the PNI > 50 group. (2.4 vs 2.6, p= 0.015). In terms of peri-operative outcomes, the PNI > 50 group was associated with shorter hospital stay (1.5 vs 2.6 days, p=<.001), however 90 day complications and readmissions were not significantly different in both groups. Although both local and metastatic recurrence was noted more in PNI > 50 group, but this difference was not statistically significant. On the KM curve, the PNI> 50 group demonstrated a better metastasis free survival, than the PNI<50 group (p=0.03).Conclusions
PNI> 50 is associated with shorter hospital stay and a better metastasis free survival following RARC. Multi-institutional studies will help better understand its use in comparing outcomes for radical cystectomy between minimally invasive and open approach.Date & Time: May 16, 2014 3:30 PM-5:30 PM
Session Title: General & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes II
Sources of Funding: None


Friday, May 16, 2014 3:30 PM-5:30 PM
OCCC: W 307
Trauma/Reconstruction: Trauma & Reconstructive Surgery II
Funding: none
MP3-17: Durability of Robotic Pyeloplasty: Long-term Outcomes of >10 Year Experience at a Single Institution 
Michael Maddox*, Allison Feibus, Sree Mandava, Mary Powers, Gregory Mitchell, Raju Thomas, New Orleans, LA

Abstract: MP3-17
Introduction and Objectives
Historically, an open dismembered pyeloplasty has been the gold standard for management of pediatric and adult ureteropelvic junction obstruction (UPJO). In the last decade there has been a considerable increase in the utilization of minimally invasive surgical correction of UPJO. We present our long-term outcomes of robotic pyeloplasty (RP) at a single institution.Methods
We retrospectively reviewed all cases of RP at our institution between November 2002 and October 2013 after Institutional Review Board approval. Procedure success was defined as resolution of symptoms, improvement in hydronephrosis or no evidence of obstruction on post-operative functional imaging. Failure of RP was defined as image-confirmed persistent UPJO and the need for a subsequent corrective procedure.Results
A total of 168 patients underwent RP during the study period. The mean patient age was 36.2 years (range 11months to 78 years). UPJO was primary (no prior attempt at correction) in 79% while 21% had previously failed endopyelotomy or pyeloplasty. A crossing vessel was encountered in 44.4% of all patients. All patients were stented during RP with mean stent duration of 42.5 days. Two complications were encountered: 1 patient developed self-limiting right shoulder pain due to positioning while 1 patient was readmitted postoperatively for pyelonephritis. 7 patients were lost to follow-up as a result of Hurricane Katrina. In the remaining 161 patients, follow-up was available for 63 patients with a mean follow-up of 23.4 months. 60 patients (95.2%) had successful RP confirmed by post-operative imaging and resolution of pre-operative symptoms. 3 patients (4.8%) failed RP resulting in 1 repeat pyeloplasty, 1 laparoscopic nephrectomy, and 1 percutaneous nephrolithotomy for persistent symptomatic UPJO.Conclusions
Robotic pyeloplasty is a safe, feasibl and effective minimally invasive technique for treating UPJO. In our long-term institutional experience, RP is a durable procedure that offers a high success rate.Date & Time: May 16, 2014 3:30 PM-5:30 PM
Session Title: Trauma/Reconstruction: Trauma & Reconstructive Surgery II
Sources of Funding: none


Friday, May 16, 2014 3:30 PM-5:30 PM
OCCC: W 311 C
Imaging/Radiology I
Funding: National Cancer Institute (CA023100 and CA128346) and Intuitive Surgical (Sunnyvale, CA, U.S.A).
PD4-02: Fluorescence Labeled Tilmanocept Detection of Sentinel Lymph Nodes During Robotic Surgery in an Animal Model 
Michael A. Liss*, Salman Farchshchi-Heydari, Zhengtao Qin, Sean A. Hickey, David J. Hall, David R. Vera, Christopher J. Kane, La Jolla, CA

Abstract: PD4-02
Introduction and Objectives
In order to identify metastasis at robotic radical prostatectomy (RRP), increasingly extensive lymph node dissections are required. Sentinel lymph node (SNL) mapping is an evolving concept in RRP to provide a targeted LND to increase accuracy and reduce dissection. We investigate the ability of fluorescent labeled Tilmanocept, a CD206 LN receptor targeted radiopharmaceutical, to be retained in SNL for up to 36 hours for flexibility in preoperative and intraoperative imaging.Methods
We injected the footpads of 25 New Zealand white rabbits with 100 umol Technetium-99m-labeled IRDye 800CW-Tilmanocept. Two doses were examined at time points of 1 and 36 hours (n=4/group) compared to control indocyanine green (ICG). Sentinel and second level lymph nodes were dissected with the assistance of fluorescence using the FireFly endoscope and DaVinci Si surgical system modified to reduce background white light. We confirmed fluorescence intensity ex vivo (Optix MX2). Analysis with the Friedman test was used to compare within the same groups and a Mann-Whitney U Exact test between groups.Results
The ICG control group showed passage through the SNL to the second level nodes within 15 min (p>0.05). In contrast, both doses (1.7 and 8.4 nmol) had higher optical fluorescence intensity in the popliteal compared to paraaortic nodes at 1 hour (p=0.050 and p=0.097, respectively) and 36 hours (p=0.039 and p=0.050, respectively) from foot pad injection. Higher fluorescence intensity with a 8.4 nmol dose in the SNL at 1-hour compared to 36-hours (Mann-Whitney U; 19100 vs. 11629 cpsµW-1; p=0.028) and no difference in the 1.7 nmol dose (p=0.195). The SNL with 8.4 nmol had higher fluorescence than 1.7 nmol dose at both 1-hr and 36-hr time points (p<0.001 and p=0.025, respectively).Conclusions
Tilmanocept labeled with IRDye 800CW is dose dependent and can be retained in SNL for at least 36 hours, which may allow image acquisition and subsequent surgical verification.Date & Time: May 16, 2014 3:30 PM-5:30 PM
Session Title: Imaging/Radiology I
Sources of Funding: National Cancer Institute (CA023100 and CA128346) and Intuitive Surgical (Sunnyvale, CA, U.S.A).

Source: AUA 2014 

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