1393 SHOULD ANTERIOR PROSTATIC FAT DURING RADICAL PROSTATECTOMY UNDERGO PATHOLOGICAL EXAMINATION?

Vol. 187, No. 4S, Supplement, Monday, May 21, 2012

1391 INTEGRATED ROBOTIC NEAR-INFRARED FLUORESCENCE DURING ROBOTIC PARTIAL NEPHRECTOMY: CORRELATION WITH TUMOR HISTOLOGY Ronney Abaza*, Columbus, OH INTRODUCTION AND OBJECTIVES: Robotic platforms can facilitate integration of complementary technologies to augment laparoscopic surgery. A recently-introduced integration of established nearinfrared fluorescence (NIRF) technology with the robotic camera system allows surgeon-controlled visualization of tissue fluorescence after intravenous indocyanine green (ICG). Normal kidney is known to fluoresce with ICG when exposed to 806nm wavelength laser light due to bilitranslocase transport of ICG into proximal tubule cells, a protein absent in clear cell renal cell carcinoma (cRCC). This may allow differential fluorescence of normal kidney and cRCC, possibly allowing better visualization of tumor borders during robotic partial nephrectomy (RPN). Additionally, bilitranslocase is present in oncocytoma, which may allow differentiation from cRCC intraoperatively if the tumor fluoresces. We evaluated fluorescence of renal tumors during RPN and compared this with tumor histology to determine the reliability of integrated robotic NIRF imaging. METHODS: RPN was performed with integrated NIRF imaging in 20 patients. Intraoperative assessment of tumor fluorescence was prospectively recorded at the time of surgery by the surgeon before pathologic assessment of tumors. Final histology was compared with NIRF findings. RESULTS: Mean age (range) was 58yrs (26-89) with mean body mass index of 31kg/m2 (18-44). Mean preoperative estimated GFR was 93mL/min (43-151). Mean tumor size on imaging studies was 4.3cm (1.8-9.7) with mean R.E.N.A.L. nephrometry score of 9.0 (6-12), including 10 hilar tumors and 15 tumors ⬎50% endophytic. Mean operative time, blood loss, and warm ischemia time were 184min, 132cc, and 14.5min, respectively, with no positive margins. One tumor could not be assessed for fluorescence due to adherent fat covering the tumor. Among 5 tumors that fluoresced, 3 were oncocytomas, 1 was cRCC, and 1 was chromophobe RCC, which is known to express bilitranslocase. Of 14 tumors that did not fluoresce, 10 were cRCC, 1 was an oncocytic neoplasm, 1 was an oncocytoma, and 1 was a known angiomyolipoma. Among 11 cRCCs, 10 did not fluoresce. Overall, 15 tumors (79%) behaved as would be predicted based on histology. CONCLUSIONS: Integrated robotic NIRF imaging was highly reliable (91%) in visualizing differential fluorescence of cRCC and surrounding normal parenchyma but less so in predicting histology. Further study is needed to determine whether this improves outcomes of RPN either by reducing positive margins or increasing preservation of normal renal tissue during resections. Source of Funding: None

1392 AUTOLOGOUS RETROPUBIC URETHRAL SLING: A NOVEL, QUICK, INTRA-OPERATIVE TECHNIQUE FOR IMPROVING CONTINENCE AFTER ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY Jacqueline D. Villalta*, Sanoj Punnen, Jared M. Whitson, Janet E. Cowan, Peter R. Carroll, San Francisco, CA INTRODUCTION AND OBJECTIVES: Post-prostatectomy urinary incontinence has a significant impact on quality of life. We describe a novel technique using the medial umbilical ligament or vas deferens as a urethral sling placed at the time of robotic assisted laparoscopic prostatectomy (RALP) and evaluate its impact on postoperative continence. METHODS: In 2011, men who underwent sling placement were compared to men who did not have a sling placed. Sling placement involved harvesting a segment of the medial umbilical ligament or vas deferens, placing it under the vesico-urethral anastomosis, affixing it to the pubic symphysis, and adjusting the tension to create a slight

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elevation of the vesicourethral angle. The association of sling placement on time to no pads per day (PPD) was assessed using Cox proportional hazards regression analysis. In addition, multivariate forward stepwise-selection was used to identify factors that were associated with early continence. RESULTS: The study cohort consisted of 46 men who underwent sling placement and 19 men who did not during the same time period. Median follow-up was 2 months in the sling patients and 5 months in the non-sling patients (p⫽0.15). Clinical and pathological characteristics were similar between the groups, except Gleason score, with sling patients displaying more high-grade disease (p⫽0.02). The placement of a sling was associated with a two-fold increased likelihood of requiring no PPD on univariate analysis (HR 2.0; 95% CI 1.02-3.97; p⫽0.04). After adjustment for age, pre-operative IPSS, prostate weight and surgical Gleason, the association barely lost statistical significance. However, there was a definite trend towards improved continence with sling placement (HR 2.1; 95% CI 0.98-4.34; p⫽0.06). Furthermore, multivariate analysis with forward stepwise selection found placement of a sling to be the only factor significantly associated with time to no pad use (HR 2.2; 95% CI 1.05-4.39; p⫽0.04). CONCLUSIONS: The placement of an autologous urethral sling was associated with improved likelihood of complete continence following RALP. The procedure takes little time. A randomized controlled trial is planned to better assess the value of sling placement on urinary continence following such surgery. Source of Funding: None

1393 SHOULD ANTERIOR PROSTATIC FAT DURING RADICAL PROSTATECTOMY UNDERGO PATHOLOGICAL EXAMINATION? Brooke Harnisch*, Boston, MA; Charlotte Caligiuri, Kevin Tomera, Alexander Perepletchikov, Ingolf Tuerk, Brighton, MA INTRODUCTION AND OBJECTIVES: Dissection of the anterior fat overlying the prostate allows for visualization during robotic assisted laparoscopic radical prostatectomy (RARP). Although not usually sent enbloc for pathological analysis, anterior prostatic fat (APF) can harbor lymph nodes involved with prostate cancer. The purpose of this study was to evaluate APF and the incidence for positive nodes. METHODS: An IRB approved retrospective study was conducted between July 2010 and October 2011 on patients who underwent RARP with ⫾ pelvic lymph node dissection and had APF sent for pathologic analysis. Clinical and pathological data was analyzed. RESULTS: A total of 302 patients were identified. Perioperative patient characteristics are summarized in Table 1. Overall, 30/302 patients (10%) had APF lymph nodes (range 1-3) and 272 patients (90%) had no APF lymph nodes. Four of 302 patients (1.3%) had positive APF nodes. Two patients had concomitant positive pelvic lymph nodes (PLN). The pre-operative biopsy Gleason score and prostate specific antigen was 4⫹3 and 5.6 ng/ml for patient 1, 4⫹3 and 2.6 ng/ml for patient 2, 4⫹3 and 5.1 ng/ml for patient 3, 3⫹4 and 6.4 ng/ml for patient four. Pathological data is summarized in Table 2. CONCLUSIONS: APF lymph nodes were present in 10% of patients with no clinical or pathological characteristics that could identify these men. Four of 302 patients (1.3%) had positive APF nodes. Pathological upstaging occurred in 2/304 patients (0.7%). Since lymph node involvement is a significant prognosticator for adjuvant treatment including radiation and hormone therapies, routine excision and pathologic analysis of the APF should be considered during RARP. Future studies with large cohorts of patients are needed to validate our findings.

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Patient age

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Table 1. Perioperative patient characteristics APF nodes APF nodes not present present (n⫽30) (n⫽272) 60.7 ⫾ 6.7 59.4 ⫾ 10.9

1395 P value 0.35

BMI (kg/m2)

27.9 ⫾ 11.6

29.3 ⫾ 3.7

0.08

Pre-op PSA

6.8 ⫾ 10.8

6.9 ⫾ 6.8

0.99

7 ⫾ 0.8

6.7 ⫾ 0.8

0.89

Average Gleason biopsy score OR time (minutes)

121⫾27

125 ⫾ 22

0.42

EBL (mls)

169 ⫾ 169

154 ⫾ 97

0.47

Table 2. Pathological data

Patient one

Seminal vesicle invasion (⫺)

Extraprostatic extension (⫺)

Perineural invasion (⫹)

Lymphovascular invasion (⫺)

Patient two

(⫺)

(⫺)

(⫹)

(⫹)

No

pT2cN1Mx

Patient three

(⫹)

(⫹)

(⫹)

(⫹)

Yes

pT3bN1Mx

Patient four

(⫹)

(⫹)

(⫹)

(⫹)

Yes

pT3bN1Mx

Positive PLN No

Pathological staging pT2aN1Mx

Source of Funding: None

1394 TECHNICAL RAY OF HOPE IN THE CONTEXT OF MINIMALLY INVASIVE URINARY DIVERSION: SEWING WITH THE PROTOTYPE DEVICE ENDOSEW® - RESULTS OF AN INTRAOPERATIVE HUMAN PILOT SERIES Beat Roth*, Frederic D. Birkhaeuser, George N. Thalmann, Pascal Zehnder, Bern, Switzerland INTRODUCTION AND OBJECTIVES: Minimally invasive cystectomy is rapidly developing. However, complete intracorporeal confection of the urinary diversion remains challenging. Therefore, stapler devices are widely used to facilitate the reconstructive part of the procedure despite the known risk of infections and stone formation. Our goal was to evaluate feasibility and safety of an absorbable running suture for ileal conduits using the prototype sewing device EndoSew®. METHODS: Consecutive series of 10 patients scheduled for urinary diversion with an ileal conduit. In order to close the proximal end of the resected bowel segment an extracorporeal running suture (Vicryl 3-0) was performed with the use of the prototype device EndoSew®. Feasibility and time requirements of the procedure were analyzed as were the number of stitches and length of suture line. Water tightness of the suture line was assessed with methylene blue intraoperatively and with loopographies on postoperative day 7 and 14. Technical requirements and complications were recorded as were overall and intervention specific complications occurring within 30d following surgery. RESULTS: A complete running suture with EndoSew® was feasible in all but 1 patient (90%). Median suturing time was 5.5min (range:3-10), median suture length was 4.5cm (range:2-5.5). In three patients, an additional single freehand stitch was needed at the beginning and/or the end of the suture line in order to anchor the running machine thread. In one patient, suturing with the device had to be abandoned due to a mechanical problem after 50% of the suturing distance. Finally, all conduits were watertight at any time. No suture related complications were observed. CONCLUSIONS: We present the first consecutive series of patients undergoing urinary diversion with an ileal conduit using the sewing device prototype EndoSew®. The procedure per se is feasible and safe. All sutures were watertight. Therefore, EndoSew® has the potential to facilitate the intracorporeal confection of the urinary diversion. However, technical refinements are necessary. Source of Funding: None

ADVANTAGE OF BARBED SUTURES FOR VESICO-URETHRAL ANASTOMOSIS DURING DA-VINCI RADICAL PROSTATECTOMY Julien Renard*, Alessandro Caviezel, Julien Schwartz, Christophe E. Iselin, Geneva, Switzerland INTRODUCTION AND OBJECTIVES: During Da Vinci radical prostatectomy (PRDV), urethro-vesical anastomosis is performed with running sutures whose tension needs to be constant to achieve a waterproof reconstruction. New “barbed” sutures which prevent loss of running suture tension have recently been available. We assess their efficacy in comparison to classical sutures. METHODS: All patients treated by PRDV with the use of barbed (V-locTM180) sutures were included. Each anastomosis entailed 2 half running sutures with posterior reconstruction, performed by 3 different operators. Waterproofness was verified performing cystography on postop day 10 before catheter removal, and in case of leakage at time of catheter removal. We compared these cases to a group of patients previously operated with classical sutures We analyzed operative and anastomosis time as well as time to catheter removal and the presence of urinary leakage. RESULTS: 44 patients underwent PRDV using V-locTM180 from June 2010 to March 2011.One patient (2.3%) presented leakage requiring bladder catheterization for 20 days. Of the 44 patients of the control group, 3 (6.8%) showed leakage requiring catheterization for a mean 21.3 days (20-22). All other had catheter removal at 10 post-operative days without complications. Mean anastomosis time was significantly shorter in the V-locTM180 group (24.4 versus 30 minutes; p⫽0.01). No significant difference was found in terms of urinary leakage (p⫽0.39) nor operative time (p⫽0.45). CONCLUSIONS: The use of barbed sutures during PRDV reduces significantly anastomosis time and allows a reduction in urinary leakage from 7 to 2%, This has led us to renounce to postop cystographic control. Source of Funding: None

1396 STEEP TRENDELENBURG POSITION DURING ROBOTIC PELVIC SURGERY DOES NOT AFFECT CARDIAL FUNCTION AND HEMODYNAMIC OUTPUT AS MEASURED BY CONTINUOUS TRANSOESOPHAGEAL ECHOCARDIOGRAPHY Andreas Becker*, Sebastian Haas, Thomas Kubitz, Alwin Goetz, Alexander Haese, Hamburg, Germany INTRODUCTION AND OBJECTIVES: Robotic assisted laparoscopic radical prostatectomy (RALP) is a continuously upcoming procedure in prostate cancer surgery. To provide optimal conditions for surgical access in RALP steep Trendelenburg positioning (STP) of the patient is necessary. STP is suspected to be associated with cardiac impairment and right ventricular dysfunction especially when capnoperitoneum is applicated like in RALP. The aim of our clinical trial was to explore hemodynamic consequences by advanced hemodynamic monitoring and to analyze myocardial and valvular function by transoesophageal echocardiography in STP during urological procedures in transperitoneal pelvic approach. METHODS: 10 patients were enrolled, 9 with RALP and 1 with robotic assisted laparoscopic cystoprostatectomy. Hemodynamic measurements and echocardiography were performed before (T1), 10 min (T2) and 60 min (T3) after STP and capnoperitoneum. RESULTS: Patients physical status classification by the American society of anaesthesiology revealed a score of 2.5 ⫾ 1,7. Blood loss in all patients was below 300 ml and no blood transfusion was required. Heart rate remained nearly unchanged (T1: 74.8 ⫾ 3.1; T2: 75.2 ⫾ 2.81; T3: 77.3 ⫾ 2.91 min-1). Mean arterial pressure (T1: 69.7 ⫾ 1.55; T2: 82.9 ⫾ 3.05 mmHg), central venous pressure (T1: