The incidence of small renal masses (SRMs) has increased in recent years in line with increased in abdominal imaging. SRMs are defined as enhancing solid lesions measuring ≤ 4cm. We present our experience with percutaneous renal tumour biopsy (RTB) of SRMs, which to our knowledge, is the largest to date.
Methods:
We reviewed our database to ascertain the incidence of benign, malignant and non-diagnostic biopsies of SRMs performed at our institution from 2001 to July 2013. A total of 519 RTBs were performed (496 SRMs). The diagnostic rate was compared over time. The accuracy of the biopsies was correlated with the definitive pathology in the cases where the biopsy led to surgery.
Results:
The mean size of the 519 biopsied lesions was 2.5 (±0.9) cm. The diagnostic rate at the first biopsy was 89.1% (442/496). Of the diagnostic biopsies, 116 (26.2%) were benign and 326 (73.7%) were malignant. Of the 54 non-diagnostic biopsies, 23 (42.6%) had a repeat biopsy. A diagnosis was obtained in 19 cases (82.6%; 8 [42.1%] benign, 11 [57.9%] malignant). Therefore RTB led to a diagnosis in 461 of the 496 SRMs (92.9%). Over time, there was a decrease in the rate of non-diagnostic biopsies from 15.0% to 6.0% (p>0.05). Of the available surgical pathology, there was agreement between histology in 92.5% (125/135). For the conventional cell carcinoma (n=85), there was concordance between histology and grade in 97.6% (83/85) and 96.1% (74/77), respectively.
Conclusions:
RTB of SRMs provided a diagnosis in 92.9% of the cases. Surgery was avoided in more than 23% of patients following RTB because of benign histology. The rate of non-diagnostic biopsies diminished over time. Finally, there was a high correlation between the biopsy and the final pathology with regards to both histology and grade. In an era where overdiagnosis and overtreatment of favourable cancers is gaining attention, routine RTB for SRM leads to diminished intervention and, going forward ,personalization of care.
Introduction and Objectives:
To assess laser prostatectomy skills of postgraduate trainees (PGTs) during the annual Quebec Urology Objective Structured Clinical Examinations (OSCEs).
Methods:
After obtaining Institutional Review Board (IRB) approval and written informed consent, urology PGTs in Post-Graduate Years (PGY-3 to PGY-5) from all 5 urology training programs in Quebec were recruited to participate in assessment of their laser Photoselective Vaporization of the Prostate (PVP) skills using the GreenLight-SIM™ (GL-SIM) during two annual OSCEs on December 1, 2012 and December 7, 2013. PGTs were asked to perform 2 excercises: anatomical identification and PVP of a 30 g normal prostate within a 20-minute station. Grams resected, global scores and number of correct anatomical landmarks were recorded and correlated with PGY level, training on GL-SIM and previous PVP experience.
Results:
25 PGTs were recruited at each OSCE with 13 PGTs participating in both OSCEs. PGTs had performed on average 2.8 and 4.5 PVP cases (p>0.05) prior to the first and second OSCEs, respectively. When comparing scores from the 1st to the 2nd OSCE, there was a significant increase in the number of grams resected (2.9±0.2 vs. 3.4±0.4 g; p=0.003) and global score (100±15 vs. 165±26; p=0.03). Whereas PGY level and previous PVP experience did not significantly affect grams resected and global score (p>0.05), previous practice on the GL-SIM significantly increased global score (100.6±19.6 vs. 162.6±22.4; p=0.04) and grams resected (3.1±0.27 vs. 4.1±0.36; p=0.04). For the 13 PGTs who participated at both OSCEs. there was significant improvement in the global score (107±21 vs. 219±31; p=0.003) and grams resected (2.9±0.3 vs. 5.2±0.5; p=0.001) from the first to the second OSCE.
Conclusions:
Performance on the GreenLight-SIM at OSCEs significantly correlated with previous practice on the GL-SIM simulator rather than PGY level or previous PVP experience.
Introduction and Objectives:
Interfascial nerve-sparing technique during RARP may be performed on the contralateral side of unilaterally diagnosed prostate cancer. Unsuspected bilateral disease could be associated with extraprostatic extension. We aim to assess the incidence and risk factors of contralateral EPE (cEPE) and contralateral positive surgical margins (cPSM) in patients diagnosed preoperatively with unilateral disease.
Methods:
This multicentre cohort consisted of 331 men diagnosed with unilateral PCa who underwent RARP. Localization and occurrence of positive cores from biopsy, cEPE, cPSM and SVI was noted (Table 1). cEPE+ and cEPE- groups were compared for preoperative predictive parameters.
Results:
Pathology reported cPCa in 50.2% and cEPE in 4% of the cohort. PSA levels of cEPE+ and cEPE- patients was 6.4 μg/L (5.1–14.6) and 5.2 μg/L (4.0–7.1) respectively (p=0.026). Proportion of positive cores (p=0.189), maximum cancer involvement in a core (p=0.168), clinical stage (p=0.327), Gleason score (p=0.178) and TRUS size (p=0.411) was also assessed. Logistic regression also identified PSA as a predictive factor of cEPE with an OR of 1.138 (CI 95% 1.032–1.255, p=0.01) per one-unit increase in PSA. Lastly, in the pT3 subgroup the presence of positive biopsies at the apex demonstrated an increased risk of cPCa and cEPE (p=0.007).
Conclusions:
Despite the 50% chance of bilateral disease, the risk of cPSM associated with cEPE is only 1% in the cohort. Contralateral nerve-sparing procedures may be considered safe in patients with unilateral disease on preoperative biopsies, especially when associated with a low PSA and negative biopsies at the apex.
Introduction and Objectives:
Vasectomy is a safe method of male contraception, with low failure and low complication rates, still it is used by only 5.7% of all US men aged 15 to 44. 45% of men report finding the decision to undergo a vasectomy difficult, with anxiety and anticipation of pain being the main deterrents. This study was undertaken to compare the prevasectomy anticipated pain scores with immediate post-vasectomy patient actual reported pain scores, in a cohort of 55 consecutive men undergoing office based No-Needle No-Scalpel vasectomy (NNNSV).
Method:
Retrospective chart review was done. Data was collected in real time by asking all patients their anticipation of pain using FACES™ visual analog pain scale. Using 1% Lidocaine in a Madajet™ device, local anesthesia was administered and NNSV was done through single midline puncture by single surgeon (PS). Vas was occluded with titanium clips, 1 cm segment was cut, lumen was cauterized and fascia interposed. Immediately after completing the procedure the patient-reported actual pain was recorded on the above mentioned pain scale. The collection of data, recording and analysis was done independent of the operating surgeon.
Results:
Complete data was available for 51/55 men. Average age of the cohort was 36.4 yrs (range 25–52), Average pre-vasectomy pain score was 5.2 (moderate) while post-vasectomy scores averaged 1.7 (mild) (p<0.005). When stratified to patient age, patients >35 years (n=23) had higher prevasectomy expected pain scores at 5.1 compared to 4.6 for patients <35 years (n=28, p=0.26). Both populations had low post-procedure pain scores of 1.70 and 1.57, respectively (p=0.29). No patient had actual reported pain worse than anticipated pain.
Conclusions:
Most men undergoing vasectomy feared much greater pain (3X) than they reported actually experiencing. With the NNNSV technique, most of our patient population reported only minimal pain. This data may be used to counsel patient, relieve anxieties, and minimize anticipation of pain for NNSV.
Introduction:
Robotic Laparoendoscopic Single-site Surgery (R-LESS) has facilitated a truncated learning curve compared to standard LESS. To our knowledge, we are the first group to develop a R-LESS program in Canada & report our initial experience at our institution.
Methods:
In 2013, 23 R-LESS procedures were performed. Access was achieved with Gelport (21) or Single Site Port (2). A 3–4 cm incision (umbilical or paramedian) was used. We developed R-LESS approaches for partial nephrectomy (PN; 9), living donor nephrectomy (LD; 5), dismembered pyeloplasty (P; 7), radical nephrectomy (1) and adrenalectomy (1).
Results:
PN: 9 patients underwent PN with a mean tumour dimension of 3.8±1.3cm. Mean patient age is 60±11 years and BMI of 27.5±5kg/m2. Operative times (OT) were 308±44 minutes with a mean clamp time of 34±8 min. Mean estimated blood loss (EBL) was 240±130ml and average length of stay (LOS) was 5.1±1 day. Technical factors warranted an additional port in 2 patients. There were no conversions or intraoperative complications. One wound infection occurred following paramedian R-LESS incision. P: 7 patients total with a mean age of 37±19 years. Mean OT were 240±29 minutes and EBL was 150±170 ml. Mean LOS was 3.2±1.3 days. One patient required an additional retraction port and no intraoperative complications occurred. LD: 5 donors have undergone R-LESS nephrectomy. The mean age was 51±7 years & BMI was 23.3±3kg/ m2. Operative time was 268±39 minutes and EBL was 140±80 mL. LOS was 3.7±0.5 days. An additional port was used in 1 patient and all transplanted kidneys had immediate function.
Conclusions:
Apart from excellent cosmetic results, R-LESS surgical results have been excellent with low complication rates. There were no conversions to open incisions and 4/23 required an additional port for retraction. Although operative times are long, we anticipate shorter times as we gain experience with this new technology. We are investigating the impact of R-LESS on quality of life, cosmesis, pain, and convalescence.
Introduction and Objectives:
Radical cystectomy (RC) in elderly is a challenging procedure still associated with significant postoperative complications, including death. Our aim was to document RC outcomes in patients over 80 years across Quebec, and to examine potentially related factors.
Methods:
Within the RAMQ (Quebec health insurance medical services database), we used procedure codes to identify patients over 80 years who underwent RC for bladder cancer over 10 years (2000–2009), as well as their outcomes. Data obtained were retrospectively analyzed in relation to multiple parameters. The outcomes analyzed were postoperative complications and mortality rates.
Results:
A total of 275 patients over 80 years old had their RCs performed in 38 hospitals across Quebec. Among them, 33% had at least one postoperative complication and 16% had more than one complication. The cohort mortality rates at 30, 60 and 90 days were 5.8%, 9.8% and 13% respectively. From all, 44.3% of RCs were performed in 7 academic hospitals with a mortality rates at 30, 60 and 90 days approaching 2.5%, 6.5% and 9% respectively. On the other hand, community based hospitals had mortality rates at 30, 60 and 90 days reaching 8.5%, 12.4% and 16.3% respectively. The difference in mortality rates between the 2 hospital facilities was statistically significant (p<0.001). The overall survival of the cohort was 3.2 years with a death rate of 63% over the whole follow-up period. The presence of postoperative complications as well as the number of these complications significantly affected the cohort overall survival (p<0.001).
Conclusions:
Our study results suggest that patients over 80 years old have high post-RC mortality rates especially at 90 days. In addition, RCs performed in academic centres had statistically significant lower mortality rates as compared to community based hospitals. Such results can be used in the process of obtaining informed consent from elderly patients who require RC.
Introduction and Objectives:
The artificial urinary sphincter (AUS) is still the existing standard for surgical treatment of post-prostatectomy incontinence (PPI). However, implanting an AUS in the setting of previous failed AUS, urethroplasty, or radiation may be challenging. Transcorporal AUS (TCAUS) is a salvage technique that can be used in this population. The aim of our study is review the intermediate term outcomes of TCAUS at our institution.
Methods:
We performed a retrospective review of patients undergoing TCAUS for PPI over a 5-year period by a single surgeon. The primary outcome was continence (defined by requiring ≤1 pad post-operation). Secondary outcomes included patient satisfaction, improvement, and complication rates.
Results:
Twelve patients with a mean age of 71.2 years were identified. All patients had high-risk features including previous eroded AUS (5), previous urethroplasty (6), radiation therapy (3), or urethral atrophy (1). Mean duration of postoperative catheterization was 2.6 days, with a mean hospitalization of 2.8 days. Mean length of follow-up was 19.1 months. Continence was achieved in 10/12 (83.3%) and the mean change in continence pads from pre to post operation was 6.5. Urethral erosion, requiring explantation, occurred in 2/12 (16.7%). Mean length of follow-up was 19.1 months. Symptom improvement was demonstrated in 100% (12/12) with an overall satisfaction of 83.3% (10/12).
Conclusions:
TCAUS is a successful salvage procedure for patients with PPI complicated by pelvic radiation, previous failed AUS, and/or prior urethroplasty. Based on intermediate term outcomes, successful continence is achieved in 83% with an acceptable rate of complications.
Introduction and Objective
The objective of this study is to determine the practice patterns of Canadian physicians using a nationwide, multicentre database of patients treated for renal tumours.
Methods:
The Canadian Kidney Cancer Information System (CKCis) was queried retrospectively to determine the use of; active surveillance, focal ablation, nephron sparing surgery and minimally invasive surgical techniques for managing cT1 renal tumours. Descriptive statistics were performed to characterize practice patterns. Associations between patient, tumour, and hospital factors with management approaches were determined.
Results:
From 1988 to 2013, 1464 patients were treated for cT1 renal tumours at 13 participating centres and had data entered in the CKCis database. Median follow-up time was 1.95 years. Median patient age was 62.4 years and 918 (63%) patients were male. Most patients (1055; 72%) were surgically treated, and the majority of those (718; 68%) received partial nephrectomy. Among the 934 (64%) patients with T1a tumours, 514 (80%) received partial nephrectomy, compared to 147 (44%) of T1b patients. Among partial nephrectomies performed, a minimally invasive approach was used in 264 (51%) T1a tumours, compared to 34 (23%) T1b tumours. A minority of patients received radiofrequency ablation (45; 3.1%), cryoablation (6; 0.4%), and active surveillance (95; 6.5%). Unadjusted analysis indicate a lower relative risk of partial nephrectomy performed for clinical T1 tumours; using minimally invasive versus open surgical approach (RR 0.66 95% CI 0.60–0.71), in the presence of renal disease (RR 0.46 95%CI 0.30–0.70), and for stage T1b versus T1a tumours (RR 0.56 95%CI 0.49–0.63).
Conclusions:
A high proportion of patients with cT1 renal tumours receive nephron sparing surgery via minimally invasive techniques at Canadian academic centres.
Background:
Radical cystectomy (RC) represents the standard of care for patients with muscle-invasive urothelial carcinoma of the urinary bladder (UCUB). Alternative organ-conserving treatments such as chemotherapy and/or radiotherapy have gained interest. We sought to compare survival outcomes of patients according to treatment modalities, in a stage-for-stage analysis.
Methods:
We relied on the Surveillance, Epidemiology, and End Results Medicare-linked database to identify 12950 patients diagnosed with T2--T4a N0/x M0 UCUB between years 1992 and 2009. Treatment types include RC (n=5207), chemotherapy/radiation (n=2669), and surveillance (n=5074). Following instrumental variable analysis, Cox- and competing-risks regression analyses were performed for prediction of overall survival (OS) and cancer-specific mortality (CSM), respectively. All analyses were stratified according to disease stage (T2, T3, T4a).
Results:
After adjusting for potential confounders, OS was more favorable for RC relative to chemotherapy/radiation (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.02--2.40) or surveillance (HR: 1.82, 95% CI: 1.20--2.78) in patients with T2 UCUB. For the same stage, CSM rates were lower in the surgery group compared to chemotherapy/radiation (HR: 2.05, 95% CI: 1.14--3.67) or surveillance (HR: 1.95, 95% CI: 1.09--3.48). When analyses focused on individuals with more advanced disease (T3--T4a), no statistically significant difference was observed between chemotherapy/radiation relative to RC for both OS and CSM.
Conclusions:
In the current retrospective population-based cohort, RC was associated with improved survival outcomes relative to its alternative treatment counterparts. However, this effect was only observable in patients with T2 disease. Conversely, no difference between chemotherapy/radiation vs. surgery was noted in patients with more advanced disease stage.
Introduction and Objectives:
Although robotic partial nephrectomy (RPN) is increasing in application, data on RPN for pT1b-T2 tumours are scarce. We report RPN in 98 patients with pT1b-T2 tumours, the largest single-institutional experience to date.
Methods:
From our prospective database, 307 consecutive patients undergoing RPN (2009–2013) for pT1a tumours <4 cm (n=209; group I) and pT1b-T2 tumours >4 cm (n=98; group II) were identified. Patient demographics, tumour characteristics, perioperative and postoperative outcomes were retrospectively analyzed. pT2 tumours were present in 8 patients.
Results:
See Table 1.
Conclusions:
Robotic partial nephrectomy is a safe and feasible option for highly selected patients with pT1b-T2 tumours >4 cm. Clinical and functional outcomes are comparable to those <4 cm. Longer follow-up is necessary to confirm oncologic outcomes.
