- Email: [email protected]
MP12-12 CONTRAST-ENHANCED ULTRASOUND FOR SMALL RENAL MASSES
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Saturday, May 17, 2014
MP12-10 RADIATION EXPOSURE TO MEDICAL STAFF IN THE UROLOGY OPERATING THEATRE e A PROSPECTIVE STUDY Peter Sauermann, Gabriel Schell, Julia Johannsen, Joerg Binder, Thomas Leippold, Neff Thomas, Guido Tenti*, Muensterlingen, Switzerland INTRODUCTION AND OBJECTIVES: Fluoroscopic screening is essential in urological standard surgery. However, there is only limited and inconsistent data available on the level of radiation exposure to the medical staff in the operating theatre, thus raising concerns about immediate and late effects of exposure to X-rays. METHODS: In this prospective analysis, cumulative radiation doses were measured in a three months period from January to March 2013 in the urology operating theatre. All surgical procedures requiring fluoroscopic screening (Uroskop Access, Siemens) were included. Dosimeters (Dosilabâ) were attached to the surgeon’s forehead and to the ring finger of the left hand. Radiation exposure of anesthesia staff was captured by a dosimeter that was placed on the surface of the respirator. In addition, general patient exposure in the areas outside the X-ray field was measured by a dosimeter positioned laterally of the patient’s pelvis. RESULTS: A total of 108 surgical procedures, among them 41 ureterorenoscopies, 34 ureteral stent insertions, and 33 not further specified procedures, were evaluated. The surgeon’s cumulative exposure to radiation during the entire study period and as measured via finger ring dosimeter was 6.2 mSv, at the forehead (cornea level) 1.1 mSv were measured. The general cumulative patient exposure amounted to 0.3 mSv. At the anesthesia work place, which is in about 3 meters distance from the fluoroscope, no radiation exposure was detected (0.0 mSv). CONCLUSIONS: Despite the regular need of fluoroscopic screening for diagnostic and therapeutic procedures in the urology operating theatre, cumulative radiation exposure to the surgeon’s cornea and fingers reached only one-hundredth of the maximum permissible annual dose. For the anesthesia staff as well as for the patient, no significant increase in cumulative dose was detected as compared to the natural background radiation. However, a responsible handling of the radiation source is an immediate requirement.
e109
fluoroscopy at 0.0240 0.0019 mSv/sec and 0.0029 .0005 mSv/sec, respectively (p ¼ 0.0024) . The organ specific dose rates are presented in the figure. The bone marrow, liver, stomach, spleen, pancreas and gallbladder were all exposed to significantly greater doses with the fixed table compared to the C-arm. CONCLUSIONS: Estimated organ doses and EDR are significantly higher during fluoroscopy using fixed-table compared with portable C-arm fluoroscopy. The majority of organs, including the most radio-sensitive organs, are exposed to more radiation using the fixed table. Urologists should be aware of this difference when considering operating room design and purchasing fluoroscopy equipment to perform ureteroscopy or percutaneous nephrolithotomy.
Source of Funding: None
Source of Funding: none
MP12-12 MP12-11 INCREASED RADIATION EXPOSURE FROM FLUOROSCOPY WITH FIXED TABLE VERSUS PORTABLE C-ARM Fernando Cabrera, Richard Shin*, Giao Nguyen, Chu Wang, Yi Hsuan Chung, Ramy Youssef, Charles Scales, Michael Ferrandino, Glenn Preminger, Terry Yoshizumi, Michael Lipkin, Durham, NC INTRODUCTION AND OBJECTIVES: Fluoroscopy is widely used during endourologic procedures and is associated with significant radiation exposure. Our objective was to estimate patient radiation exposure during fluoroscopy with either a fixed table or portable C-arm using a validated anthropomorphic adult male model. METHODS: A validated male anthropomorphic model was placed supine on both a cystoscopy operating room table and a fixed fluoroscopy table unit. A GE 9900 C-arm was used to perform fluoroscopy with the cystoscopy table. Metal oxide semiconductor field effect transistor dosimeters were placed at 20 organ-specific locations in the model to measure organ specific dosages. Continuous fluoroscopy was performed for three separate 5-6 minute runs. Measured organ dose rates (mGy/sec) were multiplied by their tissue weighting factor (International Commission on Radiological Protection) and summed to determine effective dose rate (EDR, mSv/sec). Values are reported as mean SD. RESULTS: The total EDR was significantly higher by an order of magnitude during fixed-table compared with portable C-arm
CONTRAST-ENHANCED ULTRASOUND FOR SMALL RENAL MASSES Tae Hoon Oh*, Seong Hoon Ahn, Whi An Kwon, Jea Whan Lee, Dong Youp Han, Seung Chul Park, Hee Jong Jeong, Ill Young Seo, Iksan, Korea, Republic of INTRODUCTION AND OBJECTIVES: Introduction : Ultrasonography (US) is highly sensitive in the detection of the renal mass. However, it may not show characterized findings to differentiate benign and malignant in small masses. The purpose of this study is to determine the diagnostic efficacy of contrastenhanced ultrasound (CEUS), US using contrast media, for small renal masses. METHODS: Materials and Methods: From January 2011 to September 2013, 71 patients underwent CEUS for evaluation of renal masses. Among of them, CEUS findings of small renal masses, renal cell carcinoma (RCC) cases (n ¼ 25) and angiomyolipoma (AML) cases (n ¼ 10) were retrospectively analyzed. The tumor echogenicity and enhancement patterns and degrees were evaluated. The diagnostic efficacy of CEUS in differentiating the two diseases was compared. RESULTS: Results: On CEUS of small renal tumors with less than 4 cm diameter, the findings of diffuse heterogeneous enhancement (observed in 76.0% of RCC and 30.0% of AML; p ¼ 0.020), wash-out from hyper-enhancement or isoenhancement to hypo-enhancement in late phase (64.0% of RCC and 20.0% of AML; p ¼ 0.027), and
THE JOURNAL OF UROLOGYâ
e110
perilesional rim-like enhancement (60.0% of RCC and 10.0% of AML; p ¼ 0.010) achieved significant difference between AML and RCC cases. The corresponding sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 80.0% (20 of 25), 70.0% (7 of 10), 87.0% (20 of 23), 58.3% (7 of 12), and 77.1% (27 of 35), respectively. CONCLUSIONS: Conclusion: Our results suggest that the characteristic findings of CEUS features could have a potential diagnostic factor in evaluation of small renal mass. It showed a better diagnostic efficacy than US for differentiating RCC and AML. Source of Funding: none
MP12-13 RENAL ANGIOMYOLIPOMA e A LARGE SINGLE-CENTER STUDY OF ITS NATURAL HISTORY Nicole Kim, Jaimin R. Bhatt*, Antonio Finelli, Kartik Jhaveri, Patrick O. Richard, York Pei, Andrew Evans, Laura Legere, Michael Jewett, Toronto, Canada INTRODUCTION AND OBJECTIVES: Renal angiomyolipomas (AML) are vascular tumors associated with constitutive activation of mammalian target of rapamycin (mTOR) complex. AMLs can predispose patients to serious complications such as hemorrhage. They are associated with Tuberous Sclerosis (TS). The true natural history of these tumors is not well known. We hypothesise that sporadic AMLs are benign slow-growing tumors that do not require intensive follow-up or intervention. METHODS: A retrospective review of cases with renal AML was performed between 2002 and 2013, utilizing a unique web-crawler radiology software (Montague application) and Radiology Information System (RIS), with search words ‘renal or kidney + angiomyolipoma). Patient demographics, tumor progression (increase in size of maximal axial dimension or need for intervention), and genetic status data were collected and analyzed. RESULTS: The web-crawler yielded 2741 individual patients with a diagnosis of renal AMLs reported on any radiology reports. We focused on cases with 3 or more images in order to assess the natural history and growth rate. Data were collected completely in 358 of 466 such cases. There was a female preponderance of 80.7%. There were 19 cases of tuberous sclerosis (TS). The mean age of the entire cohort at diagnosis was 58 years, compared to 31 for the TS group. Majority of AMLs were <4cm (85%), and were asymptomatic, being picked up on imaging for other reasons. They were bilateral in 17%. Of those < 4cm, only 1% required intervention, compared to 31.5% of AMLs >4cms. Of the remaining AMLs <4cm that did not require intervention, only 3.3% grew over time. In comparison, 27% of AMLs > 4cm grew. However, for the TS group, the initial tumor size was larger (78.5% were >4cm), and both the growth and intervention rates were significantly higher. Up to 43% of all TS cases required intervention compared to 5% for entire cohort. The growth rates for TS were 67% and 50% for tumors < or >4cm respectively. CONCLUSIONS: To our knowledge, this series is the world’s largest single center study of renal AMLs. We believe that most sporadic AMLs are stable in size and seldom require intervention or intensive follow-up, but those associated with TS present with greater size, multiple foci, complications, and significant tumor progression, and may be potentially offered upfront targeted treatment to reduce complications. We recommend further investigation into patients with higher growth rates to help identify important genomic or phenotypic markers which can personalize surveillance strategies. Source of Funding: None
Vol. 191, No. 4S, Supplement, Saturday, May 17, 2014
MP12-14 VASCULAR TARGETED PHOTODYNAMIC THERAPY IN THE SWINE URETER: TRANSMURAL ABLATION DOES NOT PRODUCE OBSTRUCTION IN THE SUBACUTE SETTING Ashley Winter*, Simon Kimm, Haruyuki Takaki, Sebastien Monette, New York, NY; Avigdor Scherz, Rehovot, Israel; Jonathan Coleman, New York, NY INTRODUCTION AND OBJECTIVES: An ideal technology for endoscopic management of upper tract urothelial tumors can penetrate the ureteral wall without resulting in perforation or obstruction. We created transmural ureteral ablations using percutaneously deployed vascular-targeted photodynamic therapy (VTP) in normal swine and monitored them for development of hydronephrosis and renal function deterioration. METHODS: 5 female Yorkshire pigs were utilized. The photosensitizing agent, WST-11, was infused at a dose of 4mg/kg. Percutaneous access to the renal pelvis and ureter was established with ultrasound guidance. Light was delivered through a 2.0cm cylindrical diffusing fiber for 10 minutes at laser fluence of 200mW/cm. Animals underwent CT-urography at 24hrs, 1wk, and 2wks post-procedure. Blood-urea nitrogen (BUN) and creatinine levels were drawn at quarantine and prior to each CT. Animals were euthanized at 24hrs, 1 or 2 weeks. Kidneys, ureters, and bladder were harvested and submitted for review. RESULTS: There was no change in BUN/Cr in any animal relative to baseline. No hydronephrosis or urine extravasation was noted weeks (Fig 1). Trichrome staining demonstrated preservation of ureteral collagen at 24hrs and restructuring of ablated areas at 2 weeks (Fig 2). CONCLUSIONS: Vascular targeted photodynamic therapy produced transmural ureteral ablations with minimal morbidity in this pre-clinical trial.
Vol. 191, No. 4S, Supplement, Saturday, May 17, 2014
MP12-10 RADIATION EXPOSURE TO MEDICAL STAFF IN THE UROLOGY OPERATING THEATRE e A PROSPECTIVE STUDY Peter Sauermann, Gabriel Schell, Julia Johannsen, Joerg Binder, Thomas Leippold, Neff Thomas, Guido Tenti*, Muensterlingen, Switzerland INTRODUCTION AND OBJECTIVES: Fluoroscopic screening is essential in urological standard surgery. However, there is only limited and inconsistent data available on the level of radiation exposure to the medical staff in the operating theatre, thus raising concerns about immediate and late effects of exposure to X-rays. METHODS: In this prospective analysis, cumulative radiation doses were measured in a three months period from January to March 2013 in the urology operating theatre. All surgical procedures requiring fluoroscopic screening (Uroskop Access, Siemens) were included. Dosimeters (Dosilabâ) were attached to the surgeon’s forehead and to the ring finger of the left hand. Radiation exposure of anesthesia staff was captured by a dosimeter that was placed on the surface of the respirator. In addition, general patient exposure in the areas outside the X-ray field was measured by a dosimeter positioned laterally of the patient’s pelvis. RESULTS: A total of 108 surgical procedures, among them 41 ureterorenoscopies, 34 ureteral stent insertions, and 33 not further specified procedures, were evaluated. The surgeon’s cumulative exposure to radiation during the entire study period and as measured via finger ring dosimeter was 6.2 mSv, at the forehead (cornea level) 1.1 mSv were measured. The general cumulative patient exposure amounted to 0.3 mSv. At the anesthesia work place, which is in about 3 meters distance from the fluoroscope, no radiation exposure was detected (0.0 mSv). CONCLUSIONS: Despite the regular need of fluoroscopic screening for diagnostic and therapeutic procedures in the urology operating theatre, cumulative radiation exposure to the surgeon’s cornea and fingers reached only one-hundredth of the maximum permissible annual dose. For the anesthesia staff as well as for the patient, no significant increase in cumulative dose was detected as compared to the natural background radiation. However, a responsible handling of the radiation source is an immediate requirement.
e109
fluoroscopy at 0.0240 0.0019 mSv/sec and 0.0029 .0005 mSv/sec, respectively (p ¼ 0.0024) . The organ specific dose rates are presented in the figure. The bone marrow, liver, stomach, spleen, pancreas and gallbladder were all exposed to significantly greater doses with the fixed table compared to the C-arm. CONCLUSIONS: Estimated organ doses and EDR are significantly higher during fluoroscopy using fixed-table compared with portable C-arm fluoroscopy. The majority of organs, including the most radio-sensitive organs, are exposed to more radiation using the fixed table. Urologists should be aware of this difference when considering operating room design and purchasing fluoroscopy equipment to perform ureteroscopy or percutaneous nephrolithotomy.
Source of Funding: None
Source of Funding: none
MP12-12 MP12-11 INCREASED RADIATION EXPOSURE FROM FLUOROSCOPY WITH FIXED TABLE VERSUS PORTABLE C-ARM Fernando Cabrera, Richard Shin*, Giao Nguyen, Chu Wang, Yi Hsuan Chung, Ramy Youssef, Charles Scales, Michael Ferrandino, Glenn Preminger, Terry Yoshizumi, Michael Lipkin, Durham, NC INTRODUCTION AND OBJECTIVES: Fluoroscopy is widely used during endourologic procedures and is associated with significant radiation exposure. Our objective was to estimate patient radiation exposure during fluoroscopy with either a fixed table or portable C-arm using a validated anthropomorphic adult male model. METHODS: A validated male anthropomorphic model was placed supine on both a cystoscopy operating room table and a fixed fluoroscopy table unit. A GE 9900 C-arm was used to perform fluoroscopy with the cystoscopy table. Metal oxide semiconductor field effect transistor dosimeters were placed at 20 organ-specific locations in the model to measure organ specific dosages. Continuous fluoroscopy was performed for three separate 5-6 minute runs. Measured organ dose rates (mGy/sec) were multiplied by their tissue weighting factor (International Commission on Radiological Protection) and summed to determine effective dose rate (EDR, mSv/sec). Values are reported as mean SD. RESULTS: The total EDR was significantly higher by an order of magnitude during fixed-table compared with portable C-arm
CONTRAST-ENHANCED ULTRASOUND FOR SMALL RENAL MASSES Tae Hoon Oh*, Seong Hoon Ahn, Whi An Kwon, Jea Whan Lee, Dong Youp Han, Seung Chul Park, Hee Jong Jeong, Ill Young Seo, Iksan, Korea, Republic of INTRODUCTION AND OBJECTIVES: Introduction : Ultrasonography (US) is highly sensitive in the detection of the renal mass. However, it may not show characterized findings to differentiate benign and malignant in small masses. The purpose of this study is to determine the diagnostic efficacy of contrastenhanced ultrasound (CEUS), US using contrast media, for small renal masses. METHODS: Materials and Methods: From January 2011 to September 2013, 71 patients underwent CEUS for evaluation of renal masses. Among of them, CEUS findings of small renal masses, renal cell carcinoma (RCC) cases (n ¼ 25) and angiomyolipoma (AML) cases (n ¼ 10) were retrospectively analyzed. The tumor echogenicity and enhancement patterns and degrees were evaluated. The diagnostic efficacy of CEUS in differentiating the two diseases was compared. RESULTS: Results: On CEUS of small renal tumors with less than 4 cm diameter, the findings of diffuse heterogeneous enhancement (observed in 76.0% of RCC and 30.0% of AML; p ¼ 0.020), wash-out from hyper-enhancement or isoenhancement to hypo-enhancement in late phase (64.0% of RCC and 20.0% of AML; p ¼ 0.027), and
THE JOURNAL OF UROLOGYâ
e110
perilesional rim-like enhancement (60.0% of RCC and 10.0% of AML; p ¼ 0.010) achieved significant difference between AML and RCC cases. The corresponding sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 80.0% (20 of 25), 70.0% (7 of 10), 87.0% (20 of 23), 58.3% (7 of 12), and 77.1% (27 of 35), respectively. CONCLUSIONS: Conclusion: Our results suggest that the characteristic findings of CEUS features could have a potential diagnostic factor in evaluation of small renal mass. It showed a better diagnostic efficacy than US for differentiating RCC and AML. Source of Funding: none
MP12-13 RENAL ANGIOMYOLIPOMA e A LARGE SINGLE-CENTER STUDY OF ITS NATURAL HISTORY Nicole Kim, Jaimin R. Bhatt*, Antonio Finelli, Kartik Jhaveri, Patrick O. Richard, York Pei, Andrew Evans, Laura Legere, Michael Jewett, Toronto, Canada INTRODUCTION AND OBJECTIVES: Renal angiomyolipomas (AML) are vascular tumors associated with constitutive activation of mammalian target of rapamycin (mTOR) complex. AMLs can predispose patients to serious complications such as hemorrhage. They are associated with Tuberous Sclerosis (TS). The true natural history of these tumors is not well known. We hypothesise that sporadic AMLs are benign slow-growing tumors that do not require intensive follow-up or intervention. METHODS: A retrospective review of cases with renal AML was performed between 2002 and 2013, utilizing a unique web-crawler radiology software (Montague application) and Radiology Information System (RIS), with search words ‘renal or kidney + angiomyolipoma). Patient demographics, tumor progression (increase in size of maximal axial dimension or need for intervention), and genetic status data were collected and analyzed. RESULTS: The web-crawler yielded 2741 individual patients with a diagnosis of renal AMLs reported on any radiology reports. We focused on cases with 3 or more images in order to assess the natural history and growth rate. Data were collected completely in 358 of 466 such cases. There was a female preponderance of 80.7%. There were 19 cases of tuberous sclerosis (TS). The mean age of the entire cohort at diagnosis was 58 years, compared to 31 for the TS group. Majority of AMLs were <4cm (85%), and were asymptomatic, being picked up on imaging for other reasons. They were bilateral in 17%. Of those < 4cm, only 1% required intervention, compared to 31.5% of AMLs >4cms. Of the remaining AMLs <4cm that did not require intervention, only 3.3% grew over time. In comparison, 27% of AMLs > 4cm grew. However, for the TS group, the initial tumor size was larger (78.5% were >4cm), and both the growth and intervention rates were significantly higher. Up to 43% of all TS cases required intervention compared to 5% for entire cohort. The growth rates for TS were 67% and 50% for tumors < or >4cm respectively. CONCLUSIONS: To our knowledge, this series is the world’s largest single center study of renal AMLs. We believe that most sporadic AMLs are stable in size and seldom require intervention or intensive follow-up, but those associated with TS present with greater size, multiple foci, complications, and significant tumor progression, and may be potentially offered upfront targeted treatment to reduce complications. We recommend further investigation into patients with higher growth rates to help identify important genomic or phenotypic markers which can personalize surveillance strategies. Source of Funding: None
Vol. 191, No. 4S, Supplement, Saturday, May 17, 2014
MP12-14 VASCULAR TARGETED PHOTODYNAMIC THERAPY IN THE SWINE URETER: TRANSMURAL ABLATION DOES NOT PRODUCE OBSTRUCTION IN THE SUBACUTE SETTING Ashley Winter*, Simon Kimm, Haruyuki Takaki, Sebastien Monette, New York, NY; Avigdor Scherz, Rehovot, Israel; Jonathan Coleman, New York, NY INTRODUCTION AND OBJECTIVES: An ideal technology for endoscopic management of upper tract urothelial tumors can penetrate the ureteral wall without resulting in perforation or obstruction. We created transmural ureteral ablations using percutaneously deployed vascular-targeted photodynamic therapy (VTP) in normal swine and monitored them for development of hydronephrosis and renal function deterioration. METHODS: 5 female Yorkshire pigs were utilized. The photosensitizing agent, WST-11, was infused at a dose of 4mg/kg. Percutaneous access to the renal pelvis and ureter was established with ultrasound guidance. Light was delivered through a 2.0cm cylindrical diffusing fiber for 10 minutes at laser fluence of 200mW/cm. Animals underwent CT-urography at 24hrs, 1wk, and 2wks post-procedure. Blood-urea nitrogen (BUN) and creatinine levels were drawn at quarantine and prior to each CT. Animals were euthanized at 24hrs, 1 or 2 weeks. Kidneys, ureters, and bladder were harvested and submitted for review. RESULTS: There was no change in BUN/Cr in any animal relative to baseline. No hydronephrosis or urine extravasation was noted weeks (Fig 1). Trichrome staining demonstrated preservation of ureteral collagen at 24hrs and restructuring of ablated areas at 2 weeks (Fig 2). CONCLUSIONS: Vascular targeted photodynamic therapy produced transmural ureteral ablations with minimal morbidity in this pre-clinical trial.