- Email: [email protected]
908 EVALUATION OF ADEQUACY OF PATHOLOGIC SPECIMENS USING A NOVEL BACKLOADING URETEROSCOPIC BIOPSY FORCEPS
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tumor size (cm) was significantly larger in I-LPN compared to NI-LPN (2.5 vs. 2.0, p⫽0.006). All NI-LPN procedures were successfully completed without resorting to renal ischemia. Median ischemia time for I-LPN was 29 min. Median operative time (min) was 200 for I-LPN and 175 for NI-LPN (p⫽⬍0.001). Median EBL (ml) for I-LPN was 200 and 100 for NI-LPN (p⬍0.001). Preoperatively, 22% of I-LPN and 21.3% of NI-LPN had eGFR ⬍60 mL/min/1.73M2 (p⫽1.0). Post-operatively 40.9% of I-LPN and 25.5% of NI-LPN had eGFR ⬍60 mL/min/1.73M2 (p⫽0.072). Pre and post-op median creatinine levels (mg/dl) for I-LPN were 1.0 ⫾ 0.4 and 1.2 ⫾ 0.4, and for NI-LPN were 1.0 ⫾ 0.4 and 1.0 ⫾ 0.5 (p⫽0.002). On univariate analysis, development of de novo eGFR⬍60 mL/min/1.73M2 was associated with female gender (p⫽0.007), larger median tumor size (p⫽0.006), and increased operative times and estimated blood loss (p⬍0.001). Oncologic and postoperative variables were comparable. Disease free survival was 98% for I-LPN and 100% for NI-LPN. CONCLUSIONS: Non-ischemic LPN is associated with significantly improved post-operative creatinine levels when compared to ischemic LPN. Non-ischemic LPN was associated with significantly decreased EBL and shorter operative times, while other post-operative and oncologic outcomes were comparable. Non-ischemic techniques may confer advantages in terms of renal preservation. Longer-term follow-up and further investigation are requisite. Source of Funding: None
906 INTERMEDIATE ONCOLOGOC OUTCOMES FOLLOWNG ROBOTIC-ASSISTED RADICAL PROSTATECTOMY Matthew Tollefson*, Igor Frank, Rachel Carlson, R. Jeffrey Karnes, Matthew Gettman, Rochester, MN INTRODUCTION AND OBJECTIVES: Controversy has surrounded the adoption of robotic-assisted radical prostatectomy (RARP) as the widespread expansion of the procedure has largely overtaken retropubic radical prostatectomy (RRP) in incidence. However, RARP has yet to demonstrate significant improvements in functional or oncologic outcomes. Therefore, the goal of our study was to evaluate our cumulative experience with RARP in regard to intermediate oncologic outcomes, including surgical margin status, biochemical recurrence and systemic progression. METHODS: We identified 1084 patients that underwent RARP at our institution from 2003-2008. Patients were then stratified by clinical and pathologic variables into d’Amico high, intermediate and low risk group classifications. Patients were evaluated using pathologic data as well as clinical follow-up and were analyzed according to surgical margin status as well as biochemical failure, systemic progression and cancer-specific survival. Postoperative survival was estimated using the Kaplan-Meier method. RESULTS: The median age at surgery was 60 years; median PSA was 5.0 ng/mL (range 0.1-49.3). Patients were classified into low (675, 63.4%), intermediate (348, 32.7%) and high (41, 3.9%) d’Amico risk group classifications. Overall, 148 (13.7%) patients had a positive surgical margin. 91 patients (8.4%) had extraprostatic extension, seminal vesicle invasion or positive lymph nodes. With a median follow-up of 3.0 years, 49 patients (4.5%) experienced a biochemical failure, 2 patients (0.2%) experienced systemic progression and 1 patient (0.1%) died of prostate cancer following surgery. On multivariate analysis, PSA, Gleason score, pathologic stage and risk group stratification were strong predictors of recurrent disease. 5-year biochemical-free survival was 94% for low-risk patients, 86% for intermediate risk patients and 80% for high risk patients. CONCLUSIONS: RARP provides robust cancer control in the intermediate term follow up for d’Amico high, intermediate and low risk group patients. These data compare favorably with reported rates after open RRP. Traditional predictors of adverse outcomes in the general population (PSA, Gleason score and pathologic stage) continue to provide important prognostic information. Source of Funding: None
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
907 ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY IN A PREDOMINANTLY NON-SCREENED POPULATION – FINDINGS IN A SINGLE UK INSTITUTION Lisa Lavan*, John Beatty, Ben Challacombe, Tina Rashid, Elaine Wan, Tim Dudderidge, Jordan Durrant, Christopher Ogden, London, United Kingdom INTRODUCTION AND OBJECTIVES: Robotic-assisted laparoscopic prostatectomy (RALP) accounts for the majority of surgical procedures for prostate cancer in the USA. Clinical practice in the UK is following a similar trend, however the case mix comprises fewer screen detected, low risk patients. If RALP is to be adopted by UK surgeons then forerunners in the field must audit their data sets. METHODS: 325 consecutive patients, predominately nonscreened, undergoing RALP performed by a single surgeon from one institution in the UK were audited. From January 2007 patients completed pre- and post-operative functional questionnaires (IPSS, IIEF, UCLA Prostate Cancer index and SF36-v2). Pre-operative staging, histopathology, operative parameters, biochemical and functional follow-up date were recorded. RESULTS: Using D’Amico risk stratification (including MRI staging) there were 29.2% low risk, 57.0% intermediate risk and 13.8% high risk cancers in our cohort. Mean console time was 144 minutes with an average blood loss of 150ml. Median hospital stay was 2 days, with 20.5% discharged within 24 hours. The positive margin rate was 15.6% in organ confined disease (11.5% when positive apical margins excluded). Only 6 patients with positive margins (one apical) have had biochemical recurrence. 17.7% had extra-capsular spread on postoperative histology, of which 54% had clear resection margins. Overall 7% of patients have had a PSA recurrence, and 35% of these were in patients with pT3 prostate cancer. After a minimum of 12 months follow up more than 85% of patients were incontinence pad-free. CONCLUSIONS: In the UK the majority of patients are unscreened, and therefore there are greater numbers of intermediate and high risk prostate cancers. Our data supports this assumption with over 70% of patients being classified in these two groups. Despite this we have shown that RALP is safe, with satisfactory oncological and functional outcomes in intermediate and high risk groups. Source of Funding: None
908 EVALUATION OF ADEQUACY OF PATHOLOGIC SPECIMENS USING A NOVEL BACKLOADING URETEROSCOPIC BIOPSY FORCEPS Shaun Wason*, Alan Schned, John Seigne, Vernon Pais Jr, Lebanon, NH INTRODUCTION AND OBJECTIVES: Quality of ureteroscopic biopsies may be limited by the small specimen size. Dictated by the working channel of the ureteroscope, biopsy forceps of 3fr have less than 1mm3 of biopsy head volume. Utilizing a backloading design, the BIGopsy™ ureteroscopic biopsy forceps has a biopsy head larger than the working channel of the ureteroscope. Recognizing that small biopsied tissue volume may preclude adequate pathologic evaluation, we sought to assess the adequacy of surgical specimens obtained utilizing the BIGopsy™ forceps. METHODS: In accordance with our IRB, patients undergoing nephroureterectomy for suspected upper tract TCC were recruited. Surgical specimens, immediately after extirpation were examined. The most clinically suspicious region to gross examination was alternatively biopsied with a 3fr Piranha® followed by the BIGopsy™ biopsy forceps. These specimens were fixed, stained and evaluated by a single pathologist. Biopsy size and qualitative assessment of specimen adequacy were recorded. Pathologic diagnosis of the biopsy specimens were compared to the final pathologic diagnosis. RESULTS: Three nephroureterectomy specimens were evaluated. A total of 6 biopsies were obtained from the Piranha® and 5
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
biopsies from the BIGopsy™. Biopsy size from the Piranha® ranged from 1 to 8mm2, while those from the BIGopsy™ ranged from 6 to 80mm2. Average biopsy size from the Piranha® was 3.5 ⫹/- 2.8mm2 while the average biopsy size from the BIGopsy™ was 31.2 ⫹/34.6mm2. In 2 of 3 nephroureterectomy specimens, final diagnosis was high grade papillary urothelial carcinoma in accordance with both the Piranha® and BIGopsy™ specimens. In the third specimen, the final diagnosis was benign polypoid/papillary pyelitis consistent with only the BIGopsy™ specimen, while the Piranha® specimen was suspicious for a low grade papillary lesion. Subjectively, the BIGopsy™ specimens revealed less distortion and fragmentation and were easier to interpret by the pathologist. Smooth muscle was contained in 1 of 3 BIGopsy™ specimens and in none of the Piranha® specimens. CONCLUSIONS: The BIGopsy™ backloading biopsy forceps allows removal of ureteral and renal pelvic tissue larger than the standard 3fr biopsy forceps. In all 3 cases, the diagnosis based upon the BIGopsy™ biopsy agreed with the final pathologic report, one of which was pathologically misassigned as malignant by the smaller 3fr Piranha® biopsy forceps specimen. Improved biopsy quality may translate into improved ability to diagnose ureteral and renal pelvic mucosal lesions endoscopically. Source of Funding: None
909 ROBOTIC VERSUS LAPAROSCOPIC PARTIAL NEPHRECTOMY: Georges-Pascal Haber*, Wesley M. White, Rakesh Khanna, Michael A. White, Riccardo Autorino, Sebastien Crouzet, Sylvain Forest, Jihad H. Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: We present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or laparoscopic partial nephrectomy (LPN) by a single surgeon at a single institution. METHODS: Between March 2002 and August 2009, a retrospective review of medical charts of 261 consecutive patients who underwent LPN (n⫽186 ) or RPN (n⫽75) by a single surgeon (JHK) was performed. Patients were matched for age, gender, body mass index (BMI), ASA score, and tumor size, side, and location. Perioperative outcomes of both groups were compared. RESULTS: A matched Cohort of 150 patients who underwent RPN (n ⫽ 75) or LPN (n ⫽ 75) were compared. There was no significant difference between the 2 cohorts with respect to patient age (p ⫽ 0.17), BMI (p ⫽ 0.68), ASA score (p ⫽ 0.96), preoperative eGFR (p ⫽ 0.54), or tumor size (p ⫽ 0.17). Mean operative time for RPN was 200 minutes versus 197 minutes for LPN (p ⫽ 0.75). Mean EBL was higher in the RPN cohort (323mL vs 222mL, p ⫽ 0.01). There was no significant difference between the 2 cohorts with respect to warm ischemia time (18.2 min vs 20.3min, p ⫽ 0.27), length of hospitalization (p ⫽ 0.84), % change in eGFR (p ⫽ 0.80), or adverse events (p ⫽ 0.52). All surgical margins were negative. CONCLUSIONS: Although initial surgical experience with RPN was included in this study and compared to a vast experience in LPN by the same surgeon, RPN offers at least comparable outcomes to LPN with the potential of improved outcomes as experience in RPN accumulates.
THE JOURNAL OF UROLOGY姞
e355
roscopic partial nephrectomy (RALPN) has emerged offering benefits of earlier convalescence similar to traditional laparoscopy. Initially introduced to excise small exophytic tumors, RALPN has recently evolved to allow treatment of more complex renal masses. We report on the technical feasibility and early functional outcomes of RALPN for tumors greater than 4 cm. METHODS: Between 2007 and 2009, we identified 19 RALPN in 17 patients (10 with and 7 without known hereditary syndromes) treated at our institution for solid tumors greater than 4 cm. Demographic, operative, and pathologic data were collected. Renal function was assessed by serum creatinine levels, estimated glomerular filtration rate (GFR) and nuclear renal scans assessed at baseline and 3 months post-operatively. All tumors were assigned a R.E.N.A.L. nephrometry score (www.nephrometry.com). RESULTS: Patient, tumor and intraoperative data are listed in Table 1. Three of 19 cases (16%) required intraoperative conversion. No renal units were lost. Average R.E.N.A.L. nephrometry score for the largest tumor from each kidney was 8.9 (range 6-11), while the average size was 6.1 cm (range 4.1 to 15). One patient developed ureteropelvic junction obstruction requiring subsequent stenting. There were no statistically significant differences between preoperative and postoperative creatinine (0.9 mg/dL vs. 1.0 mg/dL, p⫽0.12) or eGFR (87.6 mg/dL vs. 88.7 mg/dL, p⫽ 0.81). However, there was a statistically significant decline of ipsilateral renal scan function (49.9% vs. 44.5%, p⫽0.002) at three months. No patients had evidence of recurrent disease or metastatic disease at a mean follow up of 10 months (range 1-25). CONCLUSIONS: RALPN is feasible for renal tumors greater than 4 cm and higher nephrometry scores. Although there was a modest decline in renal function of the operated unit, RALPN affords the ability to resect challenging tumors that require complex renal reconstruction. Longer follow up will be needed to further assess functional and oncologic outcomes. Patient Data Operation # / Patient #
19/17
Age, yrs (range)
46 (26 to 71)
Mean BMI (range)
28.5 (19.8 to 40.4)
Male (%)
9 (53)
Surgery on the right, # (%)
11 (58)
Hereditary Disease, # (%)
10 (59)
Tumor Data Mean Tumor per patient, # (range)
1.6 (1 to 4)
Tumor Histology, # (%) Clear Cell
11 (58)
Papillary Type 1
4 (21)
Chromophobe
2 (11)
Oncocytoma
1 (5)
Angiomyolipoma
1 (5)
Operative Data Operative Time, min (range)
317 (220 to 496)
Warm Ischemia Time, min (range)
35.6 (11 to 61)
Estimated Blood Loss, mL (range)
659.4 (100 to 1600) Table 1.
Source of Funding: Intramural NCI Source of Funding: None
911 910 ROBOT ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR TUMORS GREATER THAN 4 CM: FEASIBILITY AND EARLY FUNCTIONAL OUTCOMES Paul H. Chung*, Gopal Gupta, Ronald S. Boris, W. Marston Linehan, Peter A. Pinto, Gennady Bratslavsky, Bethesda, MD INTRODUCTION AND OBJECTIVES: The oncologic efficacy and preservation of renal function has been well established for nephron sparing surgery (NSS) with T1b tumors. Robot assisted lapa-
DEVELOPMENT OF A PROFICIENCY-BASED SKILLS TRAINING CURRICULUM FOR ROBOTIC ASSISTED LAPAROSCOPIC SURGERY Andres Silva Waissbluth*, Brian Minnillo, Natascha Sandy, Fernando Carvas, Alexandre Derevianko, Alan Retik, Hiep Nguyen, Boston, MA INTRODUCTION AND OBJECTIVES: The Fundamentals of Laparoscopic Surgery (FLS) curriculum is a validated program of training and proficiency assessment in laparoscopic surgery. No similar standard approaches to the robotic training have yet been established.
THE JOURNAL OF UROLOGY姞
tumor size (cm) was significantly larger in I-LPN compared to NI-LPN (2.5 vs. 2.0, p⫽0.006). All NI-LPN procedures were successfully completed without resorting to renal ischemia. Median ischemia time for I-LPN was 29 min. Median operative time (min) was 200 for I-LPN and 175 for NI-LPN (p⫽⬍0.001). Median EBL (ml) for I-LPN was 200 and 100 for NI-LPN (p⬍0.001). Preoperatively, 22% of I-LPN and 21.3% of NI-LPN had eGFR ⬍60 mL/min/1.73M2 (p⫽1.0). Post-operatively 40.9% of I-LPN and 25.5% of NI-LPN had eGFR ⬍60 mL/min/1.73M2 (p⫽0.072). Pre and post-op median creatinine levels (mg/dl) for I-LPN were 1.0 ⫾ 0.4 and 1.2 ⫾ 0.4, and for NI-LPN were 1.0 ⫾ 0.4 and 1.0 ⫾ 0.5 (p⫽0.002). On univariate analysis, development of de novo eGFR⬍60 mL/min/1.73M2 was associated with female gender (p⫽0.007), larger median tumor size (p⫽0.006), and increased operative times and estimated blood loss (p⬍0.001). Oncologic and postoperative variables were comparable. Disease free survival was 98% for I-LPN and 100% for NI-LPN. CONCLUSIONS: Non-ischemic LPN is associated with significantly improved post-operative creatinine levels when compared to ischemic LPN. Non-ischemic LPN was associated with significantly decreased EBL and shorter operative times, while other post-operative and oncologic outcomes were comparable. Non-ischemic techniques may confer advantages in terms of renal preservation. Longer-term follow-up and further investigation are requisite. Source of Funding: None
906 INTERMEDIATE ONCOLOGOC OUTCOMES FOLLOWNG ROBOTIC-ASSISTED RADICAL PROSTATECTOMY Matthew Tollefson*, Igor Frank, Rachel Carlson, R. Jeffrey Karnes, Matthew Gettman, Rochester, MN INTRODUCTION AND OBJECTIVES: Controversy has surrounded the adoption of robotic-assisted radical prostatectomy (RARP) as the widespread expansion of the procedure has largely overtaken retropubic radical prostatectomy (RRP) in incidence. However, RARP has yet to demonstrate significant improvements in functional or oncologic outcomes. Therefore, the goal of our study was to evaluate our cumulative experience with RARP in regard to intermediate oncologic outcomes, including surgical margin status, biochemical recurrence and systemic progression. METHODS: We identified 1084 patients that underwent RARP at our institution from 2003-2008. Patients were then stratified by clinical and pathologic variables into d’Amico high, intermediate and low risk group classifications. Patients were evaluated using pathologic data as well as clinical follow-up and were analyzed according to surgical margin status as well as biochemical failure, systemic progression and cancer-specific survival. Postoperative survival was estimated using the Kaplan-Meier method. RESULTS: The median age at surgery was 60 years; median PSA was 5.0 ng/mL (range 0.1-49.3). Patients were classified into low (675, 63.4%), intermediate (348, 32.7%) and high (41, 3.9%) d’Amico risk group classifications. Overall, 148 (13.7%) patients had a positive surgical margin. 91 patients (8.4%) had extraprostatic extension, seminal vesicle invasion or positive lymph nodes. With a median follow-up of 3.0 years, 49 patients (4.5%) experienced a biochemical failure, 2 patients (0.2%) experienced systemic progression and 1 patient (0.1%) died of prostate cancer following surgery. On multivariate analysis, PSA, Gleason score, pathologic stage and risk group stratification were strong predictors of recurrent disease. 5-year biochemical-free survival was 94% for low-risk patients, 86% for intermediate risk patients and 80% for high risk patients. CONCLUSIONS: RARP provides robust cancer control in the intermediate term follow up for d’Amico high, intermediate and low risk group patients. These data compare favorably with reported rates after open RRP. Traditional predictors of adverse outcomes in the general population (PSA, Gleason score and pathologic stage) continue to provide important prognostic information. Source of Funding: None
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
907 ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY IN A PREDOMINANTLY NON-SCREENED POPULATION – FINDINGS IN A SINGLE UK INSTITUTION Lisa Lavan*, John Beatty, Ben Challacombe, Tina Rashid, Elaine Wan, Tim Dudderidge, Jordan Durrant, Christopher Ogden, London, United Kingdom INTRODUCTION AND OBJECTIVES: Robotic-assisted laparoscopic prostatectomy (RALP) accounts for the majority of surgical procedures for prostate cancer in the USA. Clinical practice in the UK is following a similar trend, however the case mix comprises fewer screen detected, low risk patients. If RALP is to be adopted by UK surgeons then forerunners in the field must audit their data sets. METHODS: 325 consecutive patients, predominately nonscreened, undergoing RALP performed by a single surgeon from one institution in the UK were audited. From January 2007 patients completed pre- and post-operative functional questionnaires (IPSS, IIEF, UCLA Prostate Cancer index and SF36-v2). Pre-operative staging, histopathology, operative parameters, biochemical and functional follow-up date were recorded. RESULTS: Using D’Amico risk stratification (including MRI staging) there were 29.2% low risk, 57.0% intermediate risk and 13.8% high risk cancers in our cohort. Mean console time was 144 minutes with an average blood loss of 150ml. Median hospital stay was 2 days, with 20.5% discharged within 24 hours. The positive margin rate was 15.6% in organ confined disease (11.5% when positive apical margins excluded). Only 6 patients with positive margins (one apical) have had biochemical recurrence. 17.7% had extra-capsular spread on postoperative histology, of which 54% had clear resection margins. Overall 7% of patients have had a PSA recurrence, and 35% of these were in patients with pT3 prostate cancer. After a minimum of 12 months follow up more than 85% of patients were incontinence pad-free. CONCLUSIONS: In the UK the majority of patients are unscreened, and therefore there are greater numbers of intermediate and high risk prostate cancers. Our data supports this assumption with over 70% of patients being classified in these two groups. Despite this we have shown that RALP is safe, with satisfactory oncological and functional outcomes in intermediate and high risk groups. Source of Funding: None
908 EVALUATION OF ADEQUACY OF PATHOLOGIC SPECIMENS USING A NOVEL BACKLOADING URETEROSCOPIC BIOPSY FORCEPS Shaun Wason*, Alan Schned, John Seigne, Vernon Pais Jr, Lebanon, NH INTRODUCTION AND OBJECTIVES: Quality of ureteroscopic biopsies may be limited by the small specimen size. Dictated by the working channel of the ureteroscope, biopsy forceps of 3fr have less than 1mm3 of biopsy head volume. Utilizing a backloading design, the BIGopsy™ ureteroscopic biopsy forceps has a biopsy head larger than the working channel of the ureteroscope. Recognizing that small biopsied tissue volume may preclude adequate pathologic evaluation, we sought to assess the adequacy of surgical specimens obtained utilizing the BIGopsy™ forceps. METHODS: In accordance with our IRB, patients undergoing nephroureterectomy for suspected upper tract TCC were recruited. Surgical specimens, immediately after extirpation were examined. The most clinically suspicious region to gross examination was alternatively biopsied with a 3fr Piranha® followed by the BIGopsy™ biopsy forceps. These specimens were fixed, stained and evaluated by a single pathologist. Biopsy size and qualitative assessment of specimen adequacy were recorded. Pathologic diagnosis of the biopsy specimens were compared to the final pathologic diagnosis. RESULTS: Three nephroureterectomy specimens were evaluated. A total of 6 biopsies were obtained from the Piranha® and 5
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
biopsies from the BIGopsy™. Biopsy size from the Piranha® ranged from 1 to 8mm2, while those from the BIGopsy™ ranged from 6 to 80mm2. Average biopsy size from the Piranha® was 3.5 ⫹/- 2.8mm2 while the average biopsy size from the BIGopsy™ was 31.2 ⫹/34.6mm2. In 2 of 3 nephroureterectomy specimens, final diagnosis was high grade papillary urothelial carcinoma in accordance with both the Piranha® and BIGopsy™ specimens. In the third specimen, the final diagnosis was benign polypoid/papillary pyelitis consistent with only the BIGopsy™ specimen, while the Piranha® specimen was suspicious for a low grade papillary lesion. Subjectively, the BIGopsy™ specimens revealed less distortion and fragmentation and were easier to interpret by the pathologist. Smooth muscle was contained in 1 of 3 BIGopsy™ specimens and in none of the Piranha® specimens. CONCLUSIONS: The BIGopsy™ backloading biopsy forceps allows removal of ureteral and renal pelvic tissue larger than the standard 3fr biopsy forceps. In all 3 cases, the diagnosis based upon the BIGopsy™ biopsy agreed with the final pathologic report, one of which was pathologically misassigned as malignant by the smaller 3fr Piranha® biopsy forceps specimen. Improved biopsy quality may translate into improved ability to diagnose ureteral and renal pelvic mucosal lesions endoscopically. Source of Funding: None
909 ROBOTIC VERSUS LAPAROSCOPIC PARTIAL NEPHRECTOMY: Georges-Pascal Haber*, Wesley M. White, Rakesh Khanna, Michael A. White, Riccardo Autorino, Sebastien Crouzet, Sylvain Forest, Jihad H. Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: We present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or laparoscopic partial nephrectomy (LPN) by a single surgeon at a single institution. METHODS: Between March 2002 and August 2009, a retrospective review of medical charts of 261 consecutive patients who underwent LPN (n⫽186 ) or RPN (n⫽75) by a single surgeon (JHK) was performed. Patients were matched for age, gender, body mass index (BMI), ASA score, and tumor size, side, and location. Perioperative outcomes of both groups were compared. RESULTS: A matched Cohort of 150 patients who underwent RPN (n ⫽ 75) or LPN (n ⫽ 75) were compared. There was no significant difference between the 2 cohorts with respect to patient age (p ⫽ 0.17), BMI (p ⫽ 0.68), ASA score (p ⫽ 0.96), preoperative eGFR (p ⫽ 0.54), or tumor size (p ⫽ 0.17). Mean operative time for RPN was 200 minutes versus 197 minutes for LPN (p ⫽ 0.75). Mean EBL was higher in the RPN cohort (323mL vs 222mL, p ⫽ 0.01). There was no significant difference between the 2 cohorts with respect to warm ischemia time (18.2 min vs 20.3min, p ⫽ 0.27), length of hospitalization (p ⫽ 0.84), % change in eGFR (p ⫽ 0.80), or adverse events (p ⫽ 0.52). All surgical margins were negative. CONCLUSIONS: Although initial surgical experience with RPN was included in this study and compared to a vast experience in LPN by the same surgeon, RPN offers at least comparable outcomes to LPN with the potential of improved outcomes as experience in RPN accumulates.
THE JOURNAL OF UROLOGY姞
e355
roscopic partial nephrectomy (RALPN) has emerged offering benefits of earlier convalescence similar to traditional laparoscopy. Initially introduced to excise small exophytic tumors, RALPN has recently evolved to allow treatment of more complex renal masses. We report on the technical feasibility and early functional outcomes of RALPN for tumors greater than 4 cm. METHODS: Between 2007 and 2009, we identified 19 RALPN in 17 patients (10 with and 7 without known hereditary syndromes) treated at our institution for solid tumors greater than 4 cm. Demographic, operative, and pathologic data were collected. Renal function was assessed by serum creatinine levels, estimated glomerular filtration rate (GFR) and nuclear renal scans assessed at baseline and 3 months post-operatively. All tumors were assigned a R.E.N.A.L. nephrometry score (www.nephrometry.com). RESULTS: Patient, tumor and intraoperative data are listed in Table 1. Three of 19 cases (16%) required intraoperative conversion. No renal units were lost. Average R.E.N.A.L. nephrometry score for the largest tumor from each kidney was 8.9 (range 6-11), while the average size was 6.1 cm (range 4.1 to 15). One patient developed ureteropelvic junction obstruction requiring subsequent stenting. There were no statistically significant differences between preoperative and postoperative creatinine (0.9 mg/dL vs. 1.0 mg/dL, p⫽0.12) or eGFR (87.6 mg/dL vs. 88.7 mg/dL, p⫽ 0.81). However, there was a statistically significant decline of ipsilateral renal scan function (49.9% vs. 44.5%, p⫽0.002) at three months. No patients had evidence of recurrent disease or metastatic disease at a mean follow up of 10 months (range 1-25). CONCLUSIONS: RALPN is feasible for renal tumors greater than 4 cm and higher nephrometry scores. Although there was a modest decline in renal function of the operated unit, RALPN affords the ability to resect challenging tumors that require complex renal reconstruction. Longer follow up will be needed to further assess functional and oncologic outcomes. Patient Data Operation # / Patient #
19/17
Age, yrs (range)
46 (26 to 71)
Mean BMI (range)
28.5 (19.8 to 40.4)
Male (%)
9 (53)
Surgery on the right, # (%)
11 (58)
Hereditary Disease, # (%)
10 (59)
Tumor Data Mean Tumor per patient, # (range)
1.6 (1 to 4)
Tumor Histology, # (%) Clear Cell
11 (58)
Papillary Type 1
4 (21)
Chromophobe
2 (11)
Oncocytoma
1 (5)
Angiomyolipoma
1 (5)
Operative Data Operative Time, min (range)
317 (220 to 496)
Warm Ischemia Time, min (range)
35.6 (11 to 61)
Estimated Blood Loss, mL (range)
659.4 (100 to 1600) Table 1.
Source of Funding: Intramural NCI Source of Funding: None
911 910 ROBOT ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR TUMORS GREATER THAN 4 CM: FEASIBILITY AND EARLY FUNCTIONAL OUTCOMES Paul H. Chung*, Gopal Gupta, Ronald S. Boris, W. Marston Linehan, Peter A. Pinto, Gennady Bratslavsky, Bethesda, MD INTRODUCTION AND OBJECTIVES: The oncologic efficacy and preservation of renal function has been well established for nephron sparing surgery (NSS) with T1b tumors. Robot assisted lapa-
DEVELOPMENT OF A PROFICIENCY-BASED SKILLS TRAINING CURRICULUM FOR ROBOTIC ASSISTED LAPAROSCOPIC SURGERY Andres Silva Waissbluth*, Brian Minnillo, Natascha Sandy, Fernando Carvas, Alexandre Derevianko, Alan Retik, Hiep Nguyen, Boston, MA INTRODUCTION AND OBJECTIVES: The Fundamentals of Laparoscopic Surgery (FLS) curriculum is a validated program of training and proficiency assessment in laparoscopic surgery. No similar standard approaches to the robotic training have yet been established.