Faculty Bibliography

OBJECTIVES/OBJECTIVE:To evaluate the impact of cisplatin-based neoadjuvant chemotherapy (NAC) in patients who underwent nephroureterectomy for high grade (HG) upper tract urothelial carcinoma (UTUC). METHODS:Retrospective review was conducted of patients with HG UTUC from 2011 to 2017 who underwent nephroureterectomy at two institutions. Patients with eGFR > 50 mL/min/1.73m2 were considered eligible for NAC and were referred for evaluation of NAC prior to nephroureterectomy. Patient demographics, kidney function, clinical and pathologic response rates and outcomes were analyzed. RESULTS:Of 95 patients with HG UTUC meeting inclusion criteria (mean age 72.3 years, mean pre-op eGFR 57.0 mL/min/1.73m2), 61 patients were considered eligible for NAC with eGFR > 50 mL/min/1.73m2, of which 25 (41%) received NAC. Of the patients who received NAC, 80% (20/25) of patients had clinical response on imaging and 80% (20/25) had pathologic response (<pT2N0 disease) on nephroureterectomy. On final pathology, only 20% of the NAC group had ≥pT2 disease compared to 64% of patients who proceeded directly to surgery (p = 0.001). Patients who received NAC had significantly longer progression free survival (p=0.051) and overall survival (p=0.052) compared to patients who proceeded directly to surgery. No patients progressed or were deemed ineligible for surgery due to NAC. CONCLUSIONS:Cisplatin-based NAC demonstrated a high clinical and pathologic response rate in patients with HG UTUC without compromising definitive surgical treatment. Since nephroureterectomy significantly reduces kidney function and eligibility for cisplatin-based chemotherapy after surgery, patients with HG UTUC should be considered for NAC.

Blue light cystoscopy (BLC) with hexaminolevulinate (HAL) during transurethral resection of bladder cancer improves detection of non-muscle-invasive bladder cancer (NMIBC) and reduces recurrence rates. Flexible BLC was approved by the FDA in 2018 for use in the surveillance setting and was demonstrated to improve detection. Results of a phase III prospective multicentre study of blue light flexible cystoscopy (BLFC) in surveillance of intermediate-risk and high-risk NMIBC showed that 20.6% of malignancies were identified only by BLFC. Improved detection rates in the surveillance setting are anticipated to lead to improved clinical outcomes by reducing future recurrences and earlier identification of tumours that are unresponsive to therapy. Thus, BLFC has a role in surveillance cystoscopy, and determining which patients will benefit from BLFC and optimal and cost-effective ways of incorporating this technology into surveillance cystoscopy must be developed.

PURPOSE/OBJECTIVE:To provide a contemporary understanding of chronic kidney disease (CKD) and its relevance to kidney cancer surgery. To resolve points of discrepancy regarding the survival benefits of partial nephrectomy (PN) vs radical nephrectomy (RN) by critically evaluating the results of prospective and retrospective studies in the urologic literature. MATERIALS/METHODS/METHODS:A comprehensive literature search for relevant articles listed in MEDLINE® (2002-2018) was performed using keywords radical nephrectomy, partial nephrectomy, glomerular filtration rate (GFR), kidney function, and chronic kidney disease. Selected review articles and society guidelines about CKD pertinent to urology and nephrology were also assessed. RESULTS:represents a more discerning postoperative prognostic threshold. Reported survival benefits of PN over RN demonstrated in retrospective studies are likely influenced by selection bias. The lack of survival benefit in the PN cohort of the only randomized trial of PN versus RN is consistent with data demonstrating that patients in both arms of the study had relatively low risk of mortality from CKD, when accounting for etiology of CKD and post-operative GFR levels. CONCLUSIONS:. Additional factors including non-surgical causes of CKD and degree of albuminuria can also dramatically alter the consequences of CKD following kidney cancer surgery. Urologists must have a comprehensive knowledge of CKD in order to assess the risks/benefits of PN versus RN when managing tumors with increased complexity and/or oncologic aggressiveness.

BACKGROUND:Patient-specific 3D models are being used increasingly in medicine for many applications including surgical planning, procedure rehearsal, trainee education, and patient education. To date, experiences on the use of 3D models to facilitate patient understanding of their disease and surgical plan are limited. The purpose of this study was to investigate in the context of renal and prostate cancer the impact of using 3D printed and augmented reality models for patient education. METHODS:Patients with MRI-visible prostate cancer undergoing either robotic assisted radical prostatectomy or focal ablative therapy or patients with renal masses undergoing partial nephrectomy were prospectively enrolled in this IRB approved study (n = 200). Patients underwent routine clinical imaging protocols and were randomized to receive pre-operative planning with imaging alone or imaging plus a patient-specific 3D model which was either 3D printed, visualized in AR, or viewed in 3D on a 2D computer monitor. 3D uro-oncologic models were created from the medical imaging data. A 5-point Likert scale survey was administered to patients prior to the surgical procedure to determine understanding of the cancer and treatment plan. If randomized to receive a pre-operative 3D model, the survey was completed twice, before and after viewing the 3D model. In addition, the cohort that received 3D models completed additional questions to compare usefulness of the different forms of visualization of the 3D models. Survey responses for each of the 3D model groups were compared using the Mann-Whitney and Wilcoxan rank-sum tests. RESULTS:All 200 patients completed the survey after reviewing their cases with their surgeons using imaging only. 127 patients completed the 5-point Likert scale survey regarding understanding of disease and surgical procedure twice, once with imaging and again after reviewing imaging plus a 3D model. Patients had a greater understanding using 3D printed models versus imaging for all measures including comprehension of disease, cancer size, cancer location, treatment plan, and the comfort level regarding the treatment plan (range 4.60-4.78/5 vs. 4.06-4.49/5, p < 0.05). CONCLUSIONS:All types of patient-specific 3D models were reported to be valuable for patient education. Out of the three advanced imaging methods, the 3D printed models helped patients to have the greatest understanding of their anatomy, disease, tumor characteristics, and surgical procedure.

INTRODUCTION/BACKGROUND:Penectomy for PC is useful in staging, disease prognosis, and treatment. Limited studies have evaluated its surgical complications. We sought to assess these complications and determine predictive models to create a novel risk score for penectomy complications. PATIENTS AND METHODS/METHODS:A retrospective review of patients undergoing PC surgical management from the 2005-2016 American College of Surgeons National Surgical Quality Improvement Program was performed. Data were queried for partial and total penectomy among those with PC. To develop predictive models of complications, we fit LASSO logistic, random forest, and stepwise logistic models to training data using cross-validation, demographic, comorbidity, laboratory, and wound characteristics as candidate predictors. Each model was evaluated on the test data using receiver operating characteristic curves. A novel risk score was created by rounding coefficients from the LASSO logistic model. RESULTS:A total of 304 cases met the inclusion criteria. Overall incidence of penectomy complications was 19.7%, where urinary tract infection (3.0%), superficial surgical site infection (3.0%), and bleeding requiring transfusion (3.9%) were most common. LASSO logistic, random forest, and stepwise logistic models for predicting complications had area under the curve (AUC) [95% confidence interval] values of 0.66 [0.52-0.81], 0.73 [0.63-0.83], and 0.59 [0.45-0.74], respectively. Eleven variables were included in the risk score. The LASSO model-derived risk score had moderately good performance (area under the curve [95% confidence interval] 0.74 [0.66-0.82]). Using a cutoff point of 6, the score attains sensitivity 0.58, specificity 0.74, and kappa 0.26. CONCLUSION/CONCLUSIONS:PC management through penectomy is associated with appreciable complications rates. Predictive models of penectomy complications performed moderately well. Our novel prognostic risk score may allow for improved preoperative counseling and risk stratification of men undergoing surgical management of PC.

Purpose To compare the effectiveness of personalized treatment for small (≤4 cm) renal tumors versus routine partial nephrectomy (PN), accounting for various competing causes of mortality. Materials and Methods A state-transition microsimulation model was constructed to compare life expectancy of management strategies for small renal tumors by using 1 000 000 simulations in the following ways: routine PN or personalized treatment involving percutaneous ablation for risk factors for worsening chronic kidney disease (CKD), and otherwise PN; biopsy, with triage of renal cell carcinoma (RCC) to PN or ablation depending on risk factors for worsening CKD; active surveillance for growth; and active surveillance when MRI findings are indicative of papillary RCC. Transition probabilities were incorporated from the literature. Effects of parameter variability were assessed in sensitivity analysis. Results In patients of all ages with normal renal function, routine PN yielded the longest life expectancy (eg, 0.67 years in 65-year-old men with nephrometry score [NS] of 4). Otherwise, personalized strategies extended life expectancy versus routine PN: in CKD stages 2 or 3a, moderate or high NS, and no comorbidities, MRI guidance for active surveillance extended life expectancy (eg, 2.60 years for MRI vs PN in CKD 3a, NS 10); and with Charlson comorbidity index of 1 or more, biopsy or active surveillance for growth extended life expectancy (eg, 2.70 years for surveillance for growth in CKD 3a, NS 10). CKD 3b was most effectively managed by using MRI to help predict papillary RCC for surveillance. Conclusion For patients with chronic kidney disease and small renal tumors, personalized treatment selection likely extends life expectancy. © RSNA, 2019 Online supplemental material is available for this article.

OBJECTIVE:To evaluate blue-light flexible cystoscopy (BLFC) with hexaminolevulinate in the office surveillance of patients with non-muscle-invasive bladder cancer with a high risk of recurrence by assessing its impact on pain, anxiety, subjective value of the test and patient willingness to pay. MATERIALS AND METHODS:A prospective, multicentre, phase III study was conducted during which the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, Pain and 'Was It Worth It' questionnaires were administered at baseline, after surveillance with BLFC and after resection for those referred to the operating room. Comparisons of scores were performed between groups. RESULTS:A total of 304 patients were enrolled, of whom 103 were referred for surgical examination. Of these, 63 were found to have histologically confirmed malignancy. Pain levels were low throughout the study. Anxiety levels decreased after BLFC (∆ = -2.6), with a greater decrease among those with negative pathology results (P = 0.051). No differences in anxiety were noted based on gender, BLFC results, or test performance (true-positive/false-positive). Most patients found BLFC 'worthwhile' (94%), would 'do it again' (94%) and 'would recommend it to others' (91%), with no differences based on BLFC results or test performance. Most patients undergoing BLFC (76%) were willing to pay out of pocket. CONCLUSIONS:Anxiety decreased after BLFC in patients with negative pathology, including patients with false-positive results. Most of the patients undergoing BLFC were willing to pay out of pocket, found the procedure worthwhile and would recommend it to others, irrespective of whether they had a positive BLFC result or whether this was false-positive after surgery.