Faculty Bibliography

This case series highlights that extra-adrenal and recurrent pheochromocytomas can require en bloc vascular resection to achieve negative margins. Through this series of cases performed in a multidisciplinary fashion, we aim to highlight the technical aspects of these cases that can add to their complexity. Vascular invasion alone should not preclude an otherwise feasible oncologic resection.

Introduction &Objective: Endoscopic laser incision of upper tract strictures is a minimally invasive option usually utilizing the Holmium:YAG laser. The thulium fiber laser (TFL) has an effective ablation and coagulation profile that has been successfully applied for prostate enucleation and en bloc bladder tumor excision, and may make it a new option for laser incision of strictures. We review our experience and outcomes using the TFL for treatment of upper tract strictures.
Method(s): Our prospectively maintained Endourology database was queried and 15 patients with mean age of 56 underwent endoscopic stricture incision with TFL from February 2020 to January 2021. Preoperative imaging consisted of CT scans, renal scans, and ultrasonography. The procedure was performed ureteroscopically using a 200u fiber with settings of 1J and 20 Hz. Only patients with a short (< 2cm stricture) were considered candidates. Post-operative imaging was then compared to assess radiologic resolution, improvement, or worsening.
Result(s): Of the cohort, 3 had calyceal diverticula and 12 had ureteral/ureteropelvic junction (UPJ) strictures. Of these, 8 (53%) had a prior history of ureteroscopy or percutaneous nephrolithotomy, 2 (13%) had robotic reconstruction, and 2 (13%) had open reconstruction. The most common indications for surgery were stones (87%), hydronephrosis (80%), and pain (66%). Ureteral strictures were encountered at the UPJ (9), ureterovesicular junction (1), mid ureter (1), and ileal ureteral anastomosis (1). Of 12 patients with ureteral/UPJ strictures, 10 had a ten-week post op CTU/ultrasound; 6 (60%) had resolution and 4 (40%) had improved hydronephrosis. Of 3 patients with calyceal diverticulum, all had resolution of symptoms with ten-week post op ultrasound with no evidence of stone or diverticulum reformation. Of the entire cohort, 3 patients had six month post op imaging; all demonstrated maintained resolution of hydronephrosis. Every patient was discharged same day with no reported post-operative complications.
Conclusion(s): Endoscopic laser incision of ureteral strictures using TFL may be a feasible method of managing strictures requiring a minimally invasive approach. It is versatile and can be applied to treating many areas of the upper tract including calyceal diverticula, UPJ obstruction, and strictures at ureteroenteric anastomosis. Preliminary results on short term outcomes are encouraging and more long term follow up will be required to better define the TFL's potential

BACKGROUND:Several groups have proposed features to identify low-risk patients who may benefit from endoscopic kidney-sparing surgery in upper tract urothelial carcinoma (UTUC). OBJECTIVE:To evaluate standard risk stratification features, develop an optimal model to identify ≥pT2/N+ stage at radical nephroureterectomy (RNU), and compare it with the existing unvalidated models. DESIGN, SETTING, AND PARTICIPANTS/METHODS:This was a collaborative retrospective study that included 1214 patients who underwent ureterorenoscopy with biopsy followed by RNU for nonmetastatic UTUC between 2000 and 2017. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS/UNASSIGNED:We performed multiple imputation of chained equations for missing data and multivariable logistic regression analysis with a stepwise selection algorithm to create the optimal predictive model. The area under the curve and a decision curve analysis were used to compare the models. RESULTS AND LIMITATIONS/CONCLUSIONS:Overall, 659 (54.3%) and 555 (45.7%) patients had ≤pT1N0/Nx and ≥pT2/N+ disease, respectively. In the multivariable logistic regression analysis of our model, age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.0-1.03, p = 0.013), high-grade biopsy (OR 1.81, 95% CI 1.37-2.40, p < 0.001), biopsy cT1+ staging (OR 3.23, 95% CI 1.93-5.41, p < 0.001), preoperative hydronephrosis (OR 1.37 95% CI 1.04-1.80, p = 0.024), tumor size (OR 1.09, 95% CI 1.01-1.17, p = 0.029), invasion on imaging (OR 5.10, 95% CI 3.32-7.81, p < 0.001), and sessile architecture (OR 2.31, 95% CI 1.58-3.36, p < 0.001) were significantly associated with ≥pT2/pN+ disease. Compared with the existing models, our model had the highest performance accuracy (75% vs 66-71%) and an additional clinical net reduction (four per 100 patients). CONCLUSIONS:Our proposed risk-stratification model predicts the risk of harboring ≥pT2/N+ UTUC with reliable accuracy and a clinical net benefit outperforming the current risk-stratification models. PATIENT SUMMARY/UNASSIGNED:We developed a risk stratification model to better identify patients for endoscopic kidney-sparing surgery in upper tract urothelial carcinoma.

PURPOSE/OBJECTIVE:Cancer-specific survival for men with early-stage (Stage I-IIB) testicular germ cell tumors (TGCT) is greater than 90% with any management strategy. The data regarding the comparative effectiveness of surveillance, primary chemotherapy, radiotherapy, and retroperitoneal lymph node dissection (RPLND) was synthesized with a focus on oncologic outcomes, patient-reported outcomes, and short- and long-term toxicities. MATERIALS AND METHODS/METHODS:PubMed, Embase® and the Cochrane Central Register of Controlled Trials were searched from 1980 to 2018 for studies addressing the effectiveness of surveillance, chemotherapy, radiotherapy, and RPLND, according to pathology and clinical stage, for men with an early-stage TGCT. RESULTS:Cancer-specific survival ranged from 94-100% for patients with early-stage TGCT regardless of tumor histology and initial management strategy. For men with seminoma, median cancer-specific survival was 99.7% (range 97-100%), 99.5% (96.8-100%), and 100% (100-100%) among those managed by surveillance, radiotherapy, and chemotherapy, respectively. Median cancer-specific survival for men with nonseminomatous TGCT was 100% (98.6-100%), 100% (96.9-100%), and 100% (94-100%) when managed by surveillance, RPLND, and chemotherapy, respectively. Recurrence rates and toxicities varied by management strategy. For men with seminoma, surveillance, chemotherapy, and radiotherapy were associated with median recurrence rates of 15%, 2%, and 3.7%, respectively. For men with nonseminomatous TGCT, median recurrence rates were 20.5%, 3.3%, and 11.1% for surveillance, chemotherapy, and RPLND, respectively. Surveillance was associated with minimal toxicities compared to other approaches. Primary chemotherapy had the highest rate of short-term toxicities and was associated with long-term risks of metabolic syndrome, hypogonadism, renal impairment, neuropathy, infertility, and secondary malignancies. Toxicities with radiotherapy included acute dermatitis and long-term gastrointestinal complications, infertility, and high rates of secondary malignancies (2-3%). Patients undergoing RPLND had significant risk of toxicity perioperatively and long-term infertility in men with anejaculation. Transient detriments in patient-reported outcomes and quality of life were noted with all management options. CONCLUSIONS:Men with early-stage TGCT experience excellent cancer-specific survival regardless of management strategy. Management options, however, differ in terms of associated recurrence rates, short- and long-term toxicities, and patient-reported outcomes. The profile for each approach should be clearly communicated to patients and matched with patient preferences to offer the best individual outcome.

BACKGROUND:Surgical site infection (SSI) remains a significant complication after radical cystectomy (RC). Enhanced recovery after surgery (ERAS) focuses on interventions to decrease length of stay, but few address wound-related complications directly. OBJECTIVE:To determine the impact that prophylactic incisional negative pressure wound therapy (iNPWT) will have to reduce the rate of surgical site occurrences (SSOs = SSI + seroma + superficial dehiscence) after RC. DESIGN, SETTINGS, AND PARTICIPANTS/METHODS:We retrospectively reviewed patients undergoing RC by a single surgeon from 2012 to 2017. As part of our ERAS pathway, we employed prophylactic iNPWT during abdominal closure and compared it with a contemporary cohort of standard wound closure. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS/UNASSIGNED:We compared 90-d SSIs, SSOs, and readmissions between iNPWT and standard skin staple closure. Univariate and multivariate regressions were used to compare the two groups. RESULTS AND LIMITATIONS/CONCLUSIONS:We identified 158 (104 iNPWT, 54 standard) patients from 2012 to 2017. The rates of SSIs and SSOs were 9.7% and 19.0%, respectively. The overall readmission rate for the cohort was 21.5%, with 4.4% of patients requiring readmission for SSI. The iNPWT group had lower rates of SSIs (5.8% vs 16.7%, p = 0.03) and SSOs (11.5% vs 33.3%, p < 0.01). There was no difference between the groups for readmission (21.1% vs 22.2%, p = 0.5). The iNPWT protected against both SSI (odds ratio [OR] 0.89, 95% confidence interval [CI]: 0.81-0.98) and 90-d SSO (OR 0.77, 95% CI: 0.68-0.87). CONCLUSIONS:Prophylactic iNPWT is feasible after RC with a modest decrease in both 90-d SSIs and 90-d SSOs, but not readmissions. Wound closure assisted by iNPWT should be considered in RC ERAS pathways. PATIENT SUMMARY/UNASSIGNED:In this report, we looked at the impact of new vacuum suction dressing on the prevention of surgical infections after radical cystectomy (RC). We found that this wound dressing can decrease the impact of surgical infections and aid in recovery after RC.

PURPOSE:The impact of preoperative chemotherapy in patients with upper urinary tract urothelial carcinoma remains poorly investigated. We assessed the rates of pathological complete response (pT0N0/X) and downstaging (pT1N0/X or less) at radical nephroureterectomy after preoperative chemotherapy and evaluated their impact on survival. MATERIALS AND METHODS:This was an international observational study of patients who underwent preoperative chemotherapy and radical nephroureterectomy for high risk upper tract urothelial carcinoma between 2005 and 2017. Multiple imputation of chained equations was applied to account for missing values. Logistic regression analyses were performed to identify predictors of pathological response. Cox proportional hazard regression models were used to estimate recurrence-free survival, cancer specific survival and overall survival. RESULTS:A total of 267 patients met our inclusion criteria. Among included patients 82 (31%) received methotrexate, vinblastine, doxorubicin and cisplatin; 123 (46%) gemcitabine and cisplatin; 25 (9%) gemcitabine and carboplatin; and 32 (12%) other regimens. The overall rates of pathological complete response and pathological downstaging were 10.1% and 44.9%, respectively. On multivariable analysis the use of gemcitabine and cisplatin, and gemcitabine and carboplatin was not statistically different from methotrexate, vinblastine, doxorubicin and cisplatin in achieving pathological complete response and pathological downstaging, respectively. The number of administered cycles did not appear to have an effect on pathological responses. Pathological downstaging was the strongest prognostic factor for recurrence-free survival (HR 0.2, p <0.001), cancer specific survival (HR 0.19, p <0.001) and overall survival (HR 0.40, p <0.001). CONCLUSIONS:Pathological downstaging after preoperative chemotherapy is a robust prognostic factor at radical nephroureterectomy and is associated with improved survival outcomes. Although preoperative chemotherapy appears to be effective, well designed prospective studies are still needed.

OBJECTIVE:To evaluate the incidence, predictors, and survival for those small renal masses (SRM, solid mass ≤4 cm suspicious for a clinical T1a renal cell carcinoma) that disappear on imaging while undergoing active surveillance (AS). SUBJECTS/PATIENTS AND METHODS:The Delayed Intervention and Surveillance for SRM registry prospectively enrolled 739 patients with SRMs. Patients having at least 1 image showing no lesion were considered to have a "disappearing" SRM. Logistic regression assessed predictors of having a disappearing SRM and Kaplan-Meier estimates illustrated relative survival. RESULTS:Of 374 patients enrolled in AS, 22 (5.9%) experienced a disappearing SRM. Mean time to tumor disappearance was 2.0 years (SD = 1.9) and 50.0% reappeared on subsequent CT imaging. SRM disappearance, most commonly encountered on ultrasound imaging surveillance, was independently associated with tumors <1 cm on multivariable analysis (OR = 10.6 (95% CI: 1.1-100.3), P = 0.04). Furthermore, patients with disappearing SRMs were healthier than other patients on AS with no compromise in overall survival during follow-up (5-year survival = 100% vs. 73.2%, P = 0.06). CONCLUSIONS:Approximately 5% of SRM on AS will disappear during follow-up on surveillance imaging. Most of these represent artifacts of heterogeneous imaging modalities, including ultrasound, and the SRM will reappear on subsequent imaging. Given the indolent nature of these lesions, disappearance events do not require reflex repeat imaging and patients should continue AS with their original surveillance schedule intact. A smaller percentage of patients undergoing AS for a SRM may have a mass the permanently disappears.

OBJECTIVE:To determine whether use of renal mass biopsy may be associated with a reduction in surgery for patients with small, localized renal cell carcinoma (cT1aN0M0), especially among older patients and patients with greater comorbidity burden. METHODS:A total of 106,258 patients with cT1aN0M0 renal cell carcinoma from 2004-2015 were analyzed in the National Cancer Data Base. Multivariable logistic regression identified independent associations with non-surgical management, receipt of biopsy, and pathologic upstaging. Marginal effects were derived by age and comorbidity. A sensitivity analysis was conducted in years identifying patients undergoing active surveillance (2010-2015). RESULTS:There was increased use of biopsy (8.0% to 15.3%) and non-surgical management (11.7% to 15.6%) over time. Biopsy was significantly associated with use of non-surgical management (OR 4.80 (95%CI 4.58-5.02), p<0.001) as well as active surveillance (OR 1.87 (1.69-2.07), p<0.001) in the sensitivity analysis. Individual predicted probability of undergoing non-surgical management ranged from 3% to 92% (median 31.4% with use of biopsy) and increased with age and comorbidity. Pathologic tumor upstaging (≥pT3a) occurred more frequently for patients receiving biopsy compared to no biopsy (5.8% vs. 3.3%, p<0.001). After adjustment, biopsy remained a statistically significant predictor of upstaging (OR 1.31 (95%CI 1.24-1.38), p<0.001). CONCLUSIONS:Overall, biopsy demonstrated a strong, independent association with reduced use of surgery for cT1aN0M0 kidney cancer, especially with increasing age and comorbidity. The potential association of renal mass biopsy with upstaging warrants caution, but it is uncertain whether it impacts prognosis relative to true perinephric fat invasion.

PURPOSE/OBJECTIVE:Urine cytology remains an essential diagnostic tool in the surveillance of patients with non-muscle invasive bladder cancer (NMIBC). The correlation of urine cytology with biopsy specimens to determine its accuracy following induction intravesical therapy has not been investigated. METHODS:A retrospective review was performed of patients who underwent intravesical therapy for biopsy-proven non-muscle invasive disease between 2013 and 2016 at our institution. All patients uniformly underwent cytology and systematic bladder biopsies in the operating room within 12 weeks following intravesical therapy. The accuracy of urinary cytology in predicting high-grade disease recurrence following intravesical therapy was confirmed by correlating cytology results to post-treatment systematic biopsies, regardless of endoscopic findings. Only patients with complete information regarding urine cytology and pathologic biopsy results, both pre- and post-intravesical therapy, were included. RESULTS:90 cytology samples following intravesical therapy were analyzed from 76 patients who met inclusion criteria. 72 (80.0%) and 18 (20.0%) of the samples were collected from patients initially treated for high- and low-grade disease, respectively. Fifty-six (62.2%) specimens were obtained from patients following induction of bacillus Calmette-Guerin (BCG) therapy; the remainder were from patients treated with intravesical gemcitabine/docetaxel, mitomycin, or BCG/interferon. For patients treated with BCG, cytology was positive for high-grade disease in 8/15 patients with high-grade pathology on follow-up biopsy, thus demonstrating a sensitivity of 53% (95% CI 27-79%), specificity of 95% (95% CI 84-99%), positive predictive value of 80% (95% CI 44-98%), and negative predictive value of 85% (95% CI 71-94%). If cytologic interpretation was broadened to include high-grade and "suspicious for high-grade" findings, sensitivity increased to 67% (95% CI 38-88%) and specificity decreased to 88% (95% CI 74-96%). CONCLUSIONS:While urinary cytology maintains a high specificity following intravesical therapy, it demonstrates a low sensitivity for potentially aggressive high-grade urothelial carcinoma. Further evaluation of more effective, clinic-based enhanced cystoscopy techniques and biomarkers is warranted to better identify patients at risk for disease recurrence following BCG therapy.