636 MULTI-INSTITUTIONAL ANALYSIS OF ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR VS NON-HILAR LESIONS IN 282 CONSECUTIVE CASES

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We have valorised some clinical data of different types of PRCCs (mainly tumour size, necrotic changes, presence of pseudocapsula and real extrarenal growth defined, when at least 2/3 of the mass is outside the kidney’s border on a CT). RESULTS: PRCCs were described in 109 (7.6%) cases. OPRCC was in 12 (11%), PRCC type 1 in 86 (78.9%), PRCC type 2 in 8 (7.3%) and others in 3 (2.8%) cases. O-PRCCs was more frequent in men (66.7%). The patient’s mean age with O-PRCC was 67.5 ⫾ 10.9, in other PRCC 65.8 ⫾ 7.5 years, the mean tumour size was 35 ⫾ 12, in others 43 ⫾ 17 mm. Necrotic changes were described on CTs only in PRCC type 1 and 2 (31.6%), more common were sight in gross pathology (35.8% vs 33.3% in O-PRCC). We did not find statistical significant divergence in frequency of necrotic changes in PRCC’s variants (Kruskal – Wallis test p ⫽ 0.3679). Real extrarenal growth was found only in two O-PRCCs (16.7%) vs. 40.7% in PRCC type 1, but we did not see any pseudocapsula in O-PRCC. O-PRCC had more frequent invasive type of growth than PRCC type 1 (category pT3a 16.7% vs. 11.8%; category pT3b 25% vs. 14.2%) and nephrectomy was more often provided (7/12, 58.3%). PRCC type 2 category pT3b we had in 25% cases and nephrectomy we provided in 75% cases. Nobody with O-PRCC had recurrence. Fifteen patients with PRCC type 1 (17.4%) died for metastases. Three patients of those had the sarcomatoid variant PRCC type 1 (category pT3b, pT3b pN1 and pT2). Patients died 3.7, 4.7 and 6.7 months later for metastases. CONCLUSIONS: We are able to differentiate three variants of PRCC by morphology and by using immunohistochemical methods: type I, II and oncocytic. In comparison of O-PRCC with PRCC type I and II, none of the O-PRCC had pseudocapsula and none had massive necroses, we supposed the probability of rupture to be very low. Extrarenal growth is relatively rare and nephrectomy is often necessary. The malignant potential is low. The work was supported by Czech government research project MSM 0021620819 Source of Funding: None

634 EVALUATION OF SUCCESS FOR ABLATIVE RENAL MASSES: CONCERNING INACCURACY OF CROSS-SECTIONAL IMAGING Brian Stisser*, Gennady Bratslavsky, Bethesda, MD INTRODUCTION AND OBJECTIVES: As of today, success of ablative therapy is judged by the absence of enhancement or growth on cross-sectional imaging (contrast CT or MRI) after ablation. There is, however, a paucity of tissue confirmation evaluating the success of the treatment. The present study examines the correlation of radiographic imaging and post-ablation tissue via a review of the published literature. METHODS: We performed a PUBMED search of the English language literature for the following terms “renal cryoablation”, “renal radiofrequency ablation” and “ablation failure” and identified a total of 687 articles. All of the articles were reviewed for presence of either postablation biopsy or extirpative surgery on the treated kidney. A total of 24 articles met our inclusion criteria. The 24 articles included 6 in which post-ablative extirpation was performed immediately after ablation and 18 articles in which post-ablative tissue was obtained later for either radiographic suspicion, requirement of the protocol, or other medical reasons. Each of the latter 18 articles was carefully reviewed to identify correlation of the radiographic studies with pathology of extirpated tissue. RESULTS: A total of 330 lesions that originally underwent ablative therapy had post-ablation tissue available for analysis and included 89 failures (27%). Among 6 articles evaluating for presence of failures there were a total of 38 failures in 78 lesions (49%); all failures were detected by surgical resection of the extirpated lesion immediately after RFA ablation. The remaining 18 articles documented 51 tissue failures in 252 lesions that had radiographic imaging prior to the tissue acquisition (20%). Of these 51 failures, 30 were in 99 post-RFA lesions (30%) and 21 were in 153 post-cryoablation lesions (14%). All failures were detected by biopsy in 20 cases and surgical resection in 31. Of the 51 tissue failures, the contrasted CT or MRI was suspicious for failure

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in 42 patients (82%), while the remaining 9 patients (18%) with tissue failure showed no evidence of radiographic suspicion. However, among 213 lesions that were radiographically suspicious necessitating tissue biopsy or extirpation, only 49 (23%) were actual failures. CONCLUSIONS: There is a concerning inaccuracy of crosssectional imaging to define success or failure of ablative procedures. These results should be discussed with patients and argue for a prospective trial evaluating the true success of the ablative technology. Source of Funding: None

635 EXTERNAL VALIDATION OF THE PREOPERATIVE ANATOMICAL CLASSIFICATION (PADUA) FOR PREDICTION OF COMPLICATIONS RELATED TO NEPHRON-SPARING SURGERY Mesut Remzi*, Matthias Waldert, Tobias Klatte, Peter Weibl, Gerd Schu¨ller, H. Christoph Klingler, Michael Marberger, Wien, Austria INTRODUCTION AND OBJECTIVES: Recently Ficarra et al. (Eur Urol 56: 786; 2009) published a preoperative anatomical classification (PADUA) to assess the impact of anatomical parameters of renal tumors on complications related to nephron- sparing surgery (NSS). The objective of this study was to provide external validation of this classification. METHODS: 312 tumors treated with NSS were reclassified according to the PADUA classification. Thirty-one patients, who had CT/ MRI imaging at an outside institution, were excluded. All complications were graded according to the modified Clavien system (Dindo et al. Ann Surg 240: 205, 2004). Univariate and multivariate analyses were performed. Contrary to the initial report open NSS was done in cold ischemia, laparoscopic in warm ischemia. RESULTS: 68% were male and mean patient age was 61.2 ⫹/13.3 years. ECOG performance status was 0 in 76%, 1 in 22% and 2 in 2%. 30% were treated laparoscopically. 62% of the tumors were anterior. The exophytic rate was in 62% ⬎50%, in 30% ⬍50%, and 8% grew endophytic. Renal sinus involvement was observed in 16%, whereas 35% dislocated or involved the urinary collecting system. The median PADUA classification was 7 (Range 6 to 13). Overall complication rate was 20%; 8% of the cases were grade 1, 7% grade 2, 2% grade 3a, 3% grade 3b, one patient had grade 4 and none had grade 5. PADUA classification correlated with complication rate (p⫽0.014); in contrast, ECOG performance status, stage, age or tumor subtype did not. In the laparoscopic NSS group PADUA classification was significantly lower than in the open group (p⫽0.011). Ischaemic time was significantly higher in PADUA classification ⬎⫽10. CONCLUSIONS: The PADUA classification is a reliable tool to preoperatively predict the risk of complications. Additionally it may assist in selecting patients for teaching open and laparoscopic NSS. Source of Funding: None

636 MULTI-INSTITUTIONAL ANALYSIS OF ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR VS NON-HILAR LESIONS IN 282 CONSECUTIVE CASES Lori M. Dulabon*, New York, NY; Jihad H. Kaouk, Georges-Pascal Haber, Cleveland, OH; Firas Petros, Craig G. Rogers, Detroit, MI; Michael D. Stifelman, New York, NY INTRODUCTION AND OBJECTIVES: Renal hilar tumors pose additional challenges to the laparoscopic surgeon. Robotic assistance may facilitate removal of these challenging renal lesions. In order to evaluate this, we analyzed the outcomes of our robotic-assisted partial nephrectomy (RPN) series for hilar renal tumors and compared them to non-hilar renal tumors in a multi-institutional collaborative study. METHODS: After IRB approval, we reviewed 282 consecutive patients who underwent RPN at 3 institutions over a 40 month time period (June 2006-Oct 2009). Data was collected in a prospective fashion. Renal hilar lesion was defined as a renal tumor originating on the medial aspect of the kidney, abutting the renal artery/vein, and/or

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renal pelvis with involvement of the renal sinus. Patients were stratified into hilar lesions and non hilar lesions. We compared demographic, operative and post-operative outcomes of these two groups. Student-t and Fischer’s exact tests were used for statistical analysis with a p-value ⬍ 0.05 considered significant. RESULTS: Twenty seven patients had a hilar renal mass and 255 patients had non-hilar lesions. Data is summarized in Tables 1 and 2. There were no statistical differences in patient demographics except for larger tumor size in the hilar cohort. (3.36⫾1.3cm vs 2.89⫾1.5cm; p ⫽ 0.033). The only significant difference in operative outcomes was a slight increase in warm-ischemia times (WIT) for the hilar group (24.3 min vs 20.0 min; p ⫽ 0.038). There were no differences in postoperative outcomes, except for a trend for increased risk of malignancy and higher staged tumors in the hilar tumor cohort. CONCLUSIONS: This data represents the largest series of its kind, and strongly suggests that RPN is a safe, effective, and feasible option for the minimally-invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared to non-hilar tumors. As for secondary endpoints, hilar tumors appeared to be larger and had a trend for worse pathology as demonstrated by increase risk of malignancy and higher stage tumors.

Characteristic Mean Age, years, (SD)

Table 1. Demographics. Demographics Hilar Tumors (n ⫽ 27) 61.4 (12.4)

Non-Hilar Tumors (n ⫽ 255) 61.1 (11.5)

ASA Score (SD)

2.36 (0.81)

2.41 (0.61)

BMI, kg/m2, (SD)

29.1 (6.8)

30.0 (6.3)

Gender Males Females Max Tumor Size, cm (range)

20 (74%)

155 (61%)

7 (26%)

100 (39%)

3.36 ⫾ 1.3 (1.2-7.0)*

2.40⫾ 0.6 (0.7-8.5)

*p ⫽ ⬍0.05 Table 2. Operative and Peri-Operative Outcomes. Operative Outcomes Hilar Tumors Non-Hilar Tumors Characteristic (n ⫽ 27) (n ⫽ 255) Operative Time Minutes, (SD) 208 (56) 210 (61) Warm Ischemia Time, min. (SD)

24.3 (7.0)

20.0 (10.3)*

Estimated Blood Loss, mL (SD)

215 (228)

227 (223)

0 (0%)

8 (3%)

Robotic RN

0

3 (1%)

Conventional Laparosocpic PN

0

4 (1.5%)

Intra-Operative Conversion Rate (%)

Hand-Assisted Laparoscopic PN 0 Post-Operative Outcomes Hilar Tumors Characteristic (n⫽27) Length of Stay, Days (SD) 2.9 (1.8) Peri-Op Transfusion Rate Malignancy Identified

7.40%

1 (0.4%) Non-Hilar Tumors (n⫽255) 3.0 (1.6) 8.10%

24 (88%)

184 (72%)

T1a

18 (75%)

155 (84%)

T1b

1 (4%)

24 (13%)

T2

1 (4%)

0 (0%)

T3a

3 (12.5%)

5 (2.7%)

T3b

1 (4%)

N/A

3

Stage

0 71

Positive Margins

0 (0%)

5 (2%)

Post-Op Complications

1 (3%)

9 (3.5%)

Pseudoaneurysm

1 (3%)

5 (1.9%)

Urinoma

0

4 (1.6%)

*p ⫽ ⬍0.05

Source of Funding: None

Penis/Testis/Urethra: Benign & Malignant Disease II Moderated Poster 19 Monday, May 31, 2010

8:00 AM-10:00 AM

637 OUTCOMES AFTER RESECTION OF POST CHEMOTHERAPY RESIDUAL NECK MASS IN PATIENTS WITH GERM CELL TUMOR – AN UPDATE Amit Gupta*, Andrew Feifer, Geoffrey Gotto, Dennis Kraus, Brett Carver, Joel Sheinfeld, New York, NY INTRODUCTION AND OBJECTIVES: The management of residual neck mass after chemotherapy for advanced germ cell tumor (GCT) continues to evolve. We examined the histologic findings and clinical outcomes of patients who underwent neck dissection for residual neck masses. METHODS: From 1987 to 2008, 968 post chemotherapy retroperitoneal lymph node dissections (RPLND) were performed at our institution. Following institutional review board approval, we identified 41 patients who underwent a post chemotherapy residual neck mass resection. Clinical and pathologic data were obtained from a prospective surgical database. RESULTS: 39 patients presented with primary testis, 1 with retroperitoneal and 1 with mediastinal GCT. Teratoma was present in 22/41 (54%) of the patients at diagnosis. At presentation, 37 (90%) patients were clinical stage III, 2 clinical stage II and 2 clinical stage I. IGCCCG risk classification was Good in 8 and Intermediate/Poor in 29 patients. 74 post chemotherapy residual mass resections (other than neck) were performed. Of these, mediastinal (28) and lung resections (19) were the most common. In the neck dissection, 23 (56%) patients had teratoma, 14 (34%) had fibrosis, 3 (7.3%) had viable GCT and 1 had benign histology. Viable GCT was present in 1 patient on RPLND and in 5 at other resection sites (excluding neck). Overall, 7 patients had viable GCT and 23 had teratoma at extra-retroperitoneal resection sites. There was histologic discordance in 22.5% of the patients between the neck and the RPLND and in 25% between the neck and other extra-retroperitoneal resection sites. At a median followup of 44.5 months (IQR: 14.9 – 110.3) after RPLND, 16 patients recurred and 7 died of testis cancer. Five of 7 patients with residual viable cancer at extra-retroperitoneal resection sites died of disease compared to 2 of 23 with teratoma and none with fibrosis (p⬍0.001). Among the patients who died with viable cancer, viable cancer was present on resection in the retroperitoneum (1), neck (2), mediastinum (1), lung (2), brain (1), liver (1) or adrenal (1). No patient recurred in the neck. CONCLUSIONS: Resection of residual post-chemotherapy masses at different sites, in patients with advanced GCT with a residual neck mass, is indicated because of the high incidence (73%) of viable tumor or teratoma and discordance in histology between different sites (22%). Resection of residual neck mass contributes to long term survival in patients with residual teratoma (21/23, 91%) as the worst histology at extra-retroperitoneal resection sites. Source of Funding: Amit Gupta is supported by the AUA Foundation

638 COMPLICATIONS OF POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION (PCRPLND) IN ADVANCED NONSEMINOMATOUS GERM CELL TUMORS – FIRST RESULTS OF THE GERMAN TESTICULAR CANCER STUDY GROUP Axel Heidenreich*, Aachen, Germany; Christian Winter, Du¨sseldorf, Germany; David Pfister, Maria Angerer-Shpilenya, Bernhard Brehmer, Aachen, Germany; Peter Albers, Du¨sseldorf, Germany INTRODUCTION AND OBJECTIVES: PCRPLND represents an integral part of the multimodality treatment of advanced testicular