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LAPAROSCOPIC MANAGEMENT OF COEXISTING CALYCEAL DIVERTICULUM AND PERIPELVIC CYST
Vol. 179, No. 4, Supplement, Tuesday, May 20, 2008
V1597 LAPAROSCOPIC MANAGEMENT OF COEXISTING CALYCEAL DIVERTICULUM AND PERIPELVIC CYST :LOOLDP-%DGJHU +RZDUG1:LQ¿HOG,RZD&LW\,$ INTRODUCTION AND OBJECTIVE: Once diagnosed, symptomatic calyceal diverticuli and peripelvic cysts can be managed in a variety of approaches. We present out pure laparoscopic management of a coexisting calyceal diverticulum and peripelvic cyst. 0(7+2'6 8WLOL]LQJ D ODSDURVFRSLF SRUW DSSURDFK ZH exposed a calyceal diverticulum and peripelvic cyst. The diverticular wall is incised and retrograde injection of indigo carmine demonstrates continuity with the collecting system. Incision of the peripelvic cyst demonstrated no communication with the collecting system. After H[WHQVLYH IXOJHUDWLRQ ZLWK WKH DUJRQ EHDP FRDJXODWRU ÀRVHDO DQG surgicel were applied to the renal defect with excellent hemostasis. RESULTS: The patient did well postoperatively and was discharged home on POD#2. The patient developed a small urine leak ZKLFKUHVROYHGE\32'7KH¿QDOSDWKRORJ\UHYHDOHGLQÀDPPDWLRQ DQG¿EURVLV CONCLUSIONS: Calyceal diverticuli and peripelvic cysts and safely and effective be managed by a pure laparoscopic approach. Source of Funding: None
Bladder Cancer: Invasive (II) Moderated Poster Session 55 Tuesday, May 20, 2008
3:30 - 5:30 pm
1598 LYMPHOVASCULAR INVASION (LVI) IS INDEPENDENTLY ASSOCIATED WITH BLADDER CANCER RECURRENCE AND SURVIVAL IN PATIENTS WITH T1 AND NEGATIVE LYMPH NODES AT RADICAL CYSTECTOMY Amit Gupta*, Shahrokh F Shariat, Pierre I Karakiewicz, Patrick J Bastian, Ganesh S Palapattu, Mark P Schoenberg, Seth P Lerner, Arthur I Sagalowsky, Yair Lotan. Dallas, TX, Montreal, QC, Canada, Baltimore, MD, and Houston, TX. INTRODUCTION AND OBJECTIVE: Approximately 1/5th of patients with T1 urothelial cell bladder cancer experience disease recurrence after radical cystectomy despite negative lymph nodes. ,GHQWL¿FDWLRQ RI WKHVH SDWLHQWV ZRXOG DOORZ LQFOXVLRQ LQ FOLQLFDO WULDOV of adjuvant therapy and close monitoring. Our aim was to determine WKHRXWFRPHRISDWLHQWVZLWK¿QDOSDWKRORJLF71EODGGHUFDQFHUDQG identify features that would help stratify these patients. METHODS: The records of 958 consecutive patients who underwent radical cystectomy at three academic centers were reviewed. SDWLHQWV ZLWK ¿QDO SDWKRORJLF KLJKHVW RI FOLQLFDO RU SDWKRORJLFDO VWDJH 7XURWKHOLDOFDUFLQRPDZLWKRXWQRGDOPHWDVWDVHVZHUHLGHQWL¿HG The median follow-up was 38 months (range: 0.4-177). The median QXPEHURIQRGHVH[DPLQHGZDV UDQJH /9,ZDVGH¿QHGDV the presence of tumor cells within an endothelium-lined space without underlying muscular walls. The presence of an endothelial lining was an important requirement in that retraction space artifact is especially common in invasive urothelial carcinoma. RESULTS: Overall, 12/101 (11.9%) patients experienced cancer recurrence and 7/101 (6.9%) died of their cancer. The 3 yr recurrence-free survival probability (±SD) was 0.89 ±0.04. The 3 yr FDQFHUVSHFL¿F VXUYLYDO SUREDELOLW\ 6' ZDV patients had LVI and 63 (62%) had CIS. 66.7% of patients with LVI experienced disease recurrence and 50% died of bladder cancer. 17% of patients with CIS experienced disease recurrence and 10% died of bladder cancer. All the recurrences and deaths occurred in patients who had either LVI and/or CIS. On univariate survival analysis higher SDWKRORJLFDO VWDJH 7 YV 7 7D RU 7,6 +D]DUG 5DWLR +5 p=0.03), presence of CIS on cystectomy (HR:8.5, p=0.05) and LVI (HR:7.1, p=0.001) predicted cancer recurrence. On multivariate analysis, higher pathological stage (HR: 8.5, p=0.04), and LVI (HR: 4.9, p=0.01) predicted cancer recurrence. On univariate and multivariate analyses, /9, +5 S SUHGLFWHGFDQFHUVSHFL¿FVXUYLYDO3UHVHQFHRI
THE JOURNAL OF UROLOGY®
545
CIS on cystectomy (p=0.08) showed a trend but was not statistically VLJQL¿FDQW CONCLUSIONS: LVI helps identify patients with final SDWKRORJLF71XURWKHOLDOFDUFLQRPDZKRDUHDWVLJQL¿FDQWO\LQFUHDVHG ULVNRIEODGGHUFDQFHUUHFXUUHQFHDQGGHDWK7KHVHSDWLHQWVPD\EHQH¿W from adjuvant therapy and should therefore be considered for clinical trials and close monitoring. Source of Funding: None
1599 ASSESSEMENT OF THE MINIMUM NUMBER OF LYMPH NODES NEEDED AT RADICAL CYSTECTOMY IN BLADDER CANCER PATIENTS Nazareno Suardi*, Shahrokh F Shariat, Yair Lotan, Ganesh S Palapattu, Patrick J Bastian, Amit Gupta, Amnon Vazina, Mark P Schoenberg, Seth P Lerner, Arthur I Sagalowsky, Pierre I Karakiewicz. Montreal, QC, Canada, Dallas, TX, Baltimore, MD, and Houston, TX. INTRODUCTION AND OBJECTIVE: The number of lymph nodes (LNs) removed during radical cystectomy (RC) for urothelial carcinoma (UC) of the bladder affects disease progression and survival. However, no consensus exists regarding the minimum number of LNs that should be removed. The ability to identify positive lymph nodes has not yet been examined using the received operating characteristics (ROC) methodology. The goal of the current study was to determine if a minimum threshold number of nodes exists for detecting one or several positive nodes. METHODS: Between March 1984 and October 2003, 731 assessable patients underwent radical cystectomy and bilateral pelvic lymphadenectomy at three different institutions. ROC curve coordinates were used to determine the probability of diagnosing lymph node invasion according to the total number of nodes removed. Additionally, the relationship between the number of nodes removed and the rate of positive lymph nodes was tested in univariable and multivariable logistic regression models. RESULTS: Of 731 patients, 174 (23.8%) had positive lymph nodes. The mean number of lymph nodes removed was 18.7 (median 17, range: 1-80). The receiver operating characteristics coordinates plot indicated that the removal of 45 nodes yielded a 90% probability to detect one or several positive lymph nodes. The removal of 25 nodes resulted LQDSUREDELOLW\RI¿QGLQJRQHRUVHYHUDOSRVLWLYHQRGHV CONCLUSIONS: Our data indicate that at least 25 nodes VKRXOGEHUHPRYHGDWUDGLFDOF\VWHFWRP\WR¿QGRQHRUVHYHUDOSRVLWLYH nodes. Improvement of the yield of lymphadenectomy will require the removal of even more lymph nodes. This study supports a more extended LN dissection at the time of RC, and highlights the challenges of interpreting retrospective LN dissection data.
V1597 LAPAROSCOPIC MANAGEMENT OF COEXISTING CALYCEAL DIVERTICULUM AND PERIPELVIC CYST :LOOLDP-%DGJHU +RZDUG1:LQ¿HOG,RZD&LW\,$ INTRODUCTION AND OBJECTIVE: Once diagnosed, symptomatic calyceal diverticuli and peripelvic cysts can be managed in a variety of approaches. We present out pure laparoscopic management of a coexisting calyceal diverticulum and peripelvic cyst. 0(7+2'6 8WLOL]LQJ D ODSDURVFRSLF SRUW DSSURDFK ZH exposed a calyceal diverticulum and peripelvic cyst. The diverticular wall is incised and retrograde injection of indigo carmine demonstrates continuity with the collecting system. Incision of the peripelvic cyst demonstrated no communication with the collecting system. After H[WHQVLYH IXOJHUDWLRQ ZLWK WKH DUJRQ EHDP FRDJXODWRU ÀRVHDO DQG surgicel were applied to the renal defect with excellent hemostasis. RESULTS: The patient did well postoperatively and was discharged home on POD#2. The patient developed a small urine leak ZKLFKUHVROYHGE\32'7KH¿QDOSDWKRORJ\UHYHDOHGLQÀDPPDWLRQ DQG¿EURVLV CONCLUSIONS: Calyceal diverticuli and peripelvic cysts and safely and effective be managed by a pure laparoscopic approach. Source of Funding: None
Bladder Cancer: Invasive (II) Moderated Poster Session 55 Tuesday, May 20, 2008
3:30 - 5:30 pm
1598 LYMPHOVASCULAR INVASION (LVI) IS INDEPENDENTLY ASSOCIATED WITH BLADDER CANCER RECURRENCE AND SURVIVAL IN PATIENTS WITH T1 AND NEGATIVE LYMPH NODES AT RADICAL CYSTECTOMY Amit Gupta*, Shahrokh F Shariat, Pierre I Karakiewicz, Patrick J Bastian, Ganesh S Palapattu, Mark P Schoenberg, Seth P Lerner, Arthur I Sagalowsky, Yair Lotan. Dallas, TX, Montreal, QC, Canada, Baltimore, MD, and Houston, TX. INTRODUCTION AND OBJECTIVE: Approximately 1/5th of patients with T1 urothelial cell bladder cancer experience disease recurrence after radical cystectomy despite negative lymph nodes. ,GHQWL¿FDWLRQ RI WKHVH SDWLHQWV ZRXOG DOORZ LQFOXVLRQ LQ FOLQLFDO WULDOV of adjuvant therapy and close monitoring. Our aim was to determine WKHRXWFRPHRISDWLHQWVZLWK¿QDOSDWKRORJLF71EODGGHUFDQFHUDQG identify features that would help stratify these patients. METHODS: The records of 958 consecutive patients who underwent radical cystectomy at three academic centers were reviewed. SDWLHQWV ZLWK ¿QDO SDWKRORJLF KLJKHVW RI FOLQLFDO RU SDWKRORJLFDO VWDJH 7XURWKHOLDOFDUFLQRPDZLWKRXWQRGDOPHWDVWDVHVZHUHLGHQWL¿HG The median follow-up was 38 months (range: 0.4-177). The median QXPEHURIQRGHVH[DPLQHGZDV UDQJH /9,ZDVGH¿QHGDV the presence of tumor cells within an endothelium-lined space without underlying muscular walls. The presence of an endothelial lining was an important requirement in that retraction space artifact is especially common in invasive urothelial carcinoma. RESULTS: Overall, 12/101 (11.9%) patients experienced cancer recurrence and 7/101 (6.9%) died of their cancer. The 3 yr recurrence-free survival probability (±SD) was 0.89 ±0.04. The 3 yr FDQFHUVSHFL¿F VXUYLYDO SUREDELOLW\ 6' ZDV patients had LVI and 63 (62%) had CIS. 66.7% of patients with LVI experienced disease recurrence and 50% died of bladder cancer. 17% of patients with CIS experienced disease recurrence and 10% died of bladder cancer. All the recurrences and deaths occurred in patients who had either LVI and/or CIS. On univariate survival analysis higher SDWKRORJLFDO VWDJH 7 YV 7 7D RU 7,6 +D]DUG 5DWLR +5 p=0.03), presence of CIS on cystectomy (HR:8.5, p=0.05) and LVI (HR:7.1, p=0.001) predicted cancer recurrence. On multivariate analysis, higher pathological stage (HR: 8.5, p=0.04), and LVI (HR: 4.9, p=0.01) predicted cancer recurrence. On univariate and multivariate analyses, /9, +5 S SUHGLFWHGFDQFHUVSHFL¿FVXUYLYDO3UHVHQFHRI
THE JOURNAL OF UROLOGY®
545
CIS on cystectomy (p=0.08) showed a trend but was not statistically VLJQL¿FDQW CONCLUSIONS: LVI helps identify patients with final SDWKRORJLF71XURWKHOLDOFDUFLQRPDZKRDUHDWVLJQL¿FDQWO\LQFUHDVHG ULVNRIEODGGHUFDQFHUUHFXUUHQFHDQGGHDWK7KHVHSDWLHQWVPD\EHQH¿W from adjuvant therapy and should therefore be considered for clinical trials and close monitoring. Source of Funding: None
1599 ASSESSEMENT OF THE MINIMUM NUMBER OF LYMPH NODES NEEDED AT RADICAL CYSTECTOMY IN BLADDER CANCER PATIENTS Nazareno Suardi*, Shahrokh F Shariat, Yair Lotan, Ganesh S Palapattu, Patrick J Bastian, Amit Gupta, Amnon Vazina, Mark P Schoenberg, Seth P Lerner, Arthur I Sagalowsky, Pierre I Karakiewicz. Montreal, QC, Canada, Dallas, TX, Baltimore, MD, and Houston, TX. INTRODUCTION AND OBJECTIVE: The number of lymph nodes (LNs) removed during radical cystectomy (RC) for urothelial carcinoma (UC) of the bladder affects disease progression and survival. However, no consensus exists regarding the minimum number of LNs that should be removed. The ability to identify positive lymph nodes has not yet been examined using the received operating characteristics (ROC) methodology. The goal of the current study was to determine if a minimum threshold number of nodes exists for detecting one or several positive nodes. METHODS: Between March 1984 and October 2003, 731 assessable patients underwent radical cystectomy and bilateral pelvic lymphadenectomy at three different institutions. ROC curve coordinates were used to determine the probability of diagnosing lymph node invasion according to the total number of nodes removed. Additionally, the relationship between the number of nodes removed and the rate of positive lymph nodes was tested in univariable and multivariable logistic regression models. RESULTS: Of 731 patients, 174 (23.8%) had positive lymph nodes. The mean number of lymph nodes removed was 18.7 (median 17, range: 1-80). The receiver operating characteristics coordinates plot indicated that the removal of 45 nodes yielded a 90% probability to detect one or several positive lymph nodes. The removal of 25 nodes resulted LQDSUREDELOLW\RI¿QGLQJRQHRUVHYHUDOSRVLWLYHQRGHV CONCLUSIONS: Our data indicate that at least 25 nodes VKRXOGEHUHPRYHGDWUDGLFDOF\VWHFWRP\WR¿QGRQHRUVHYHUDOSRVLWLYH nodes. Improvement of the yield of lymphadenectomy will require the removal of even more lymph nodes. This study supports a more extended LN dissection at the time of RC, and highlights the challenges of interpreting retrospective LN dissection data.