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Background Non–guideline-directed care (NGDC) is seen in ∼30% of testicular cancer patients and has been identified as a significant predictor of relapse. However, the potential impact of mismanagement on patient quality of life (QoL) is yet to be established. Objective To explore the impact of NGDC on long-term QoL in testicular cancer survivors (TCSs). Design, setting, and participants A retrospective review of TCSs, who completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) in person or via mail ≥6 mo after completion of treatment, was conducted. Outcome measurements and statistical analysis The validated questionnaire evaluates global health status (GHS); cognitive, social, physical, emotional, and role functioning; financial burden; and treatment-specific side effects. Results and limitations A total of 120 men with a median age of 31.5 (interquartile range: 24–42) yr completed the questionnaire. Thirty-four (28%) men received NGDC: overtreatment (44%), improper imaging (32%), and undertreatment (29%). Men with NGDC presented with a more advanced clinical stage (≥IIA: 64% vs 32%, p = 0.007) and were less likely to undergo surveillance (19% vs 37%, p = 0.016). Patients receiving guideline-directed care reported higher GHS (84.1 vs 77.5, p = 0.015), higher physical function scores (98.5 vs 91.2, p = 0.013), and fewer financial difficulties (5.8 vs 18.6, p = 0.006) than those receiving NGDC. Multivariable linear regression showed a significant association between NGDC and poorer GHS (p = 0.002). Limitations of the study include its retrospective nature, modest sample size due to a 21% response rate, and quality-of-life assessment at a single time point rather than serially over time. Conclusions In addition to treatment delay, avoidable morbidity, and higher rates of relapse, NGDC leads to inferior global QoL, worse physical functioning, and more financial stress. Patient summary We have previously shown how mismanagement of testicular cancer results in a higher rate of disease relapse. In this study, we emphasize how the lack of adherence to standard treatment guidelines can lead to worse quality of life outcomes and financial stress in testicular cancer survivors.

We present a case of a 69-year-old male patient diagnosed with high grade (T1 HG) urothelial carcinoma of the bladder who progressed rapidly towards muscle invasive disease and eventually death despite neoadjuvant chemotherapy and radical cystectomy. We postulate that this may be due to a deleterious underlying somatic gene mutation. Molecular pathologic data obtained on the initial, non-muscle invasive tumor and the final cystectomy specimen, revealed the same TP53 mutation (p.Arg110Pro) in both specimens with a variant allele frequency of 44%. The tumor was tested for 50 common gene mutations in urothelial carcinoma and no other identifiable DNA repair mutations were found, suggesting that this specific TP53 aberration, one that has never been reported in the bladder cancer literature, could be particularly deleterious. Knowing that bladder cancer cell lines that lack TP53 are more resistant to cisplatin and because the tumor lacked any other DNA mutation, this patient may have been a candidate for upfront surgery without neoadjuvant chemotherapy. In addition to histological analysis of the tumor, early molecular and cytogenetic characterization of resected tissue is essential in predicting progression and eventual prognosis of the disease based on identifiable gene mutations. Further comparative prospective studies are required to clarify the importance of molecular heterogeneity and subtyping in bladder cancer.

To evaluate the perioperative and oncological/functional outcomes of robotic post-chemotherapy retroperitoneal lymph node dissection for testicular cancer.In this retrospective study, we included patients who underwent robotic post-chemotherapy retroperitoneal lymph node dissection at 7 academic centers between 2011 and 2021. Patients' characteristics, perioperative findings, as well as oncological and functional outcomes are reviewed. Relationships with the main outcome (90-day complications) were analyzed using multivariable logistic regression.A total of 90 patients with a median (IQR) age of 30 (25-37) years were included. The main primary histologic type was non-seminomatous germ cell tumor (89%). Seven patients (8%) were electively converted to open. Median estimated blood loss, operative time, and length of hospital stay were 150 ml, 5.6 hours, and 2 days, respectively. Final pathology revealed teratoma in 49 (55%), necrosis/fibrosis in 29 (32%), and viable germ cell tumor in 12 (13%) patients. The 90-day complication rate was 16.7%, most of which were low-grade (Clavien-DindoIII) and managed conservatively. On multivariable analysis, pure seminoma (odds ratio 17.4) and bilateral dissection template (odds ratio 4.2) were independently associated with 90-day complications. No 90-day hospital readmission was recorded. With a median (IQR) follow-up of 16 (4-32) months, 6 (6.7%) patients had disease recurrence and there was 1 cancer-related death.With appropriate patient selection at centers with expertise in testicular cancer and minimally invasive surgery, robotic post-chemotherapy retroperitoneal lymph node dissection appears safe and effective, although longer follow-up is warranted.

To describe the perioperative safety, functional and immediate post-operative oncological outcomes of minimally invasive RPLND (miRPLND) for testis cancer.We performed a retrospective multi-centre cohort study on testis cancer patients treated with miRPLND from 16 institutions in eight countries. We measured clinician-reported outcomes stratified by indication. We performed logistic regression to identify predictors for maintained postoperative ejaculatory function.Data for 457 men undergoing miRPLND were studied. miRPLND comprised laparoscopic (n = 56) or robotic (n = 401) miRPLND. Indications included pre-chemotherapy in 305 and post-chemotherapy in 152 men. The median retroperitoneal mass size was 32 mm and operative time 270 min. Intraoperative complications occurred in 20 (4%) and postoperative complications in 26 (6%). In multivariable regression, nerve sparing, and template resection improved ejaculatory function significantly (template vs bilateral resection [odds ratio (OR) 19.4, 95% confidence interval (CI) 6.5-75.6], nerve sparing vs non-nerve sparing [OR 5.9, 95% CI 2.3-16.1]). In 91 men treated with primary RPLND, nerve sparing and template resection, normal postoperative ejaculation was reported in 96%. During a median follow-up of 33 months, relapse was detected in 39 (9%) of which one with port site ( 1%), one with peritoneal recurrence and 10 (2%) with retroperitoneum recurrences.The low proportion of complications or peritoneal recurrences and high proportion of men with normal postoperative ejaculatory function supports further miRPLND studies.

INTRODUCTION AND OBJECTIVE:We present perioperative outcomes of our single center experience with robotic assisted ACE channel creation for the treatment of chronic constipation refractory to medic...

Renal angiomyolipomas are benign tumors of the kidney that belong to the ‘PEComa: perivascular epithelioid cell’ family. Epithelioid AMLs (eAML) are a rare monotypic subtype with malignant potential, that can occur sporadically or be associated with tuberous sclerosis (TSC). Due to their epithelioid nature, eAMLs can closely resemble high-grade renal cell carcinoma ( RCC ), which may result in misdiagnosis . Multiple clinicopathologic parameters are predictive of worse outcomes for patients with eAML. Those can be used to stratify patients into groups with low, intermediate and high risk for disease progression. A high index of suspicion and a thorough immunohistochemical study are required to correctly diagnose eAML. Radiographically, eAMLs are also a diagnostic challenge as they share features with RCC on CT and MR imaging. Due to this close mimicry, the true incidence of eAML is thought to be much higher than 200 cases as reported in the literature. We report a series of four patients diagnosed with eAML and compare their clinical courses. We also report on the successful treatment of a patient with pulmonary metastasis from eAML using the mTOR inhibitor, everolimus. By identifying eAML and recognizing its high-risk features, it is possible mTOR inhibitors may have a meaningful role in the adjuvant treatment of these patients.

Immunotherapy is now a cornerstone for cancer treatment, and much attention has been placed on the identification of prognostic and predictive biomarkers. The success of biomarker development is dependent on accurate and timely collection of biospecimens and high-quality processing, storage and shipping. Tumors are also increasingly used as source material for the generation of therapeutic T cells. There have been few guidelines or consensus statements on how to optimally collect and manage biospecimens and source material being used for immunotherapy and related research. The Society for Immunotherapy of Cancer Surgery Committee has brought together surgical experts from multiple subspecialty disciplines to identify best practices and to provide consensus on how best to access and manage specific tissues for immuno-oncology treatments and clinical investigation. In addition, the committee recommends early integration of surgeons and other interventional physicians with expertise in biospecimen collection, especially in clinical trials, to optimize the quality of tissue and the validity of correlative clinical studies in cancer immunotherapy.

410 Background: Active surveillance (AS) for stage I germ cell tumor (GCT) typically includes periodic imaging of chest, abdomen and pelvis. Efforts to modify the surveillance protocols aim to minimize radiation exposure in this young patient population. We report our multi-institutional effort to assess the effect of omitting CT pelvis. Methods: Using data from three major referral centers for GCT (University of Southern California, University of Toronto, and University of Chicago), all patients with stage I GCT who experienced recurrence on AS were selected. Clinicodemographic information including recurrence pattern (tumor marker (TM), imaging, physical exam (PE), or a combination of these) were collected. Bifurcation of the common iliac arteries was defined as the anatomic landmark between CT abdomen and pelvis. The location of recurrent nodal disease was determined accordingly. Results: A total of 270 patients were included. 122(45%) patients had non-seminomatous GCT (NSGCT). 17(6%) patients had history of cryptorchidism and 38 (14%) had history of scrotal/inguinal surgery. The median time to recurrence for seminoma and NSGCT was 16 months (IQR 8–27) and 6 months (IQR 4–13), respectively. The most common method for detecting recurrence was imaging-only (49%) followed by combination of TM and imaging (43%). A total of 43/270(16%) patients had pelvic/inguinal nodal recurrence (PNR). Prior hernia repair was significantly higher in patients with pelvic/inguinal nodal disease compared to their counterparts (19%vs2.5%;p=0.01). PNR was detectable only by imaging in 16/270(6%) patients. However, in 11/16(69%) patients, PNRe was either visible on CT abdomen cuts or there was simultaneous retroperitoneal recurrence. Overall, only 5/270(1.8%) patients (4 seminoma, 1 NSGCT) had PNR only detectable on CT pelvis. Conclusions: CT abdomen only, chest imaging, TM and PE detect majority of recurrences in stage I GCT and CT pelvis could be safely omitted during AS. Future modification in AS protocols of stage I GCT may be warranted.[Table: see text]

Background: The aim of the study was to evaluate the utility of multiparametric magnetic resonance imaging (mp-MRI)-transrectal ultrasound (TRUS) cognitively targeted biopsy in identifying the most significant cancerous lesion in the prostate to decrease the incidence of pathologic upgrading after radical prostatectomy. Methods: We conducted a retrospective review of all radical prostatectomies at the American University of Beirut Medical Center between January 2016 and 2017. Pathology reports for both, TRUS biopsy and surgically resected specimens were analyzed and compared using SPSS. Results: Among 66 patients who underwent radical prostatectomy, 44 patients underwent a standard random 12-core biopsy of the prostate, while 22 patients underwent 4 - 5 cognitively targeted biopsies. Biopsy Gleason scores were compared to surgically resected specimens. Of mp-MRI targeted biopsies, 86% were identical to the surgical specimen, while 14% were upgraded. Of the random biopsy, 55% patients upgraded after surgery, while 38% were concordant with the random biopsy result. Moreover, 13/24 patients who upgraded after random biopsy, did so from Gleason 6 (3+3) to Gleason 7 (3+4). The difference in pathological upgrading among both groups is statistically significant, and confirms the importance of MRI-TRUS cognitively targeted biopsy in identifying the highest risk lesion. This may have significant implications on the choice of treatment prior to embarking on surgical resection of prostate cancer. Conclusion: MRI-TRUS targeted biopsy is more accurate than random biopsy in identifying the most significant cancerous lesion, resulting in a decreased incidence of pathologic upgrading after prostatectomy. This may have significant implications on the choice of treatment especially in low risk prostate cancer. Larger scale multicenter studies are required. World J Nephrol Urol. 2018;7(1):12-16 doi: https://doi.org/10.14740/wjnu285w

389 Background: Organ confined (stage IA/IB) testicular cancer has a high cure rate regardless of initial treatment modality, making it important to weigh the toxicities of treatment against potential benefits. While many clinicians routinely obtain serum tumor markers (STMs) prior to radical orchiectomy, their role in predicting recurrence in stage IA and IB testicular cancer has not been studied. Methods: A multi-institutional database of stage I testicular cancer patients diagnosed between 2006 and 2018 was created. Univariate and multivariate regression models were created to understand which factors predict recurrence. Recurrence analyses using Kaplan-Meier curves for elevated and normal pre-orchiectomy STMs were also generated. Results: 150 patients met the study criteria, of whom 16 (11%) relapsed (Table). 9 (56%) patients with recurrence had elevated pre-orchiectomy STMs, and 7 (44%) had normal pre-orchiectomy STMs. Similarly, 75 patients (56%) without relapse had elevated pre-orchiectomy STMs. Of 9 patients with elevated pre-orchiectomy STMs, 6 (67%) had normal STMs at recurrence; of 7 with normal pre-orchiectomy STMs, 4 patients (57%) had elevated STMs at recurrence. On Kaplan-Meier analysis, no association between level of pre-orchiectomy STMs and recurrence free survival was observed. Conclusions: Pre-orchiectomy STMs were not independently associated with recurrence in stage I testis cancer. Interestingly, there was also no association between positivity of pre-orchiectomy STMs and whether or not STMs were elevated at recurrence. These findings support the continued use of standard-of-care imaging and STMs in surveillance of stage IA/IB testicular cancer patients regardless of pre-orchiectomy STMs. [Table: see text]

Introduction Intravesical BCG remains a first-line treatment for patients with intermediate/high risk non-muscle invasive bladder cancer (NMIBC) desiring bladder preservation. In the era of BCG shortage, alternative therapies such as sequential dual intravesical gemcitabine and docetaxel (gem/doce) have been described. We report short term outcomes of patients with BCG-Naive NMIBC treated with gem/doce in lieu of BCG. Methods Patients with high grade NMIBC who had not previously received BCG underwent visually complete TURBT followed by 6 weekly instillations of gemcitabine and docetaxel. At each instillation, patients received 1g of gemcitabine followed by 40mg of docetaxel each for 1-hour dwell. Primary outcome measure was 6-month cystoscopic response rate. Secondary outcome measures include 3-month cystoscopic response rate and progression to MIBC. Results 18 BCG-naive subjects received intravesical gem/doce and completed follow up cystoscopy. Initial staging was Ta in 10, T1 in 4, and CIS in 4. At 6-month cystoscopy, 14/18 patients (78%) were visually free of recurrence. Of the 4 patients with CIS at initial staging, 3 (75%) were visually free of recurrence at 6-month cystoscopy and had benign urine cytology. On ensuing TURBT, there were 2 histologic recurrences. One patient had progression from CIS with Ta disease to CIS with T1 disease and one had persistent T1 disease. No patient progressed to muscle invasion during follow up. There were no further instances of tumor recurrence or progression between 3 and 6 months. All patients started on gem/doce (n=18) completed induction without dose reduction or missed instillation due to adverse effects. Conclusions Sequential adjuvant gemcitabine/docetaxel intravesical therapy after TURBT shows promising 6-month response rates for BCG-naive high grade NMIBC. Longer follow up is needed to assess durable response or effects on recurrence or progression.

Background: Several studies have alluded to a detrimental impact of the surgeon’s “learning curve” on outcomes of minimally invasive surgery. In this study, we evaluated the outcomes of robotic-assisted partial nephrectomy (RAPN) versus open partial nephrectomy (OPN) for kidney tumors, during the introduction of Robotic Urologic Oncology at our institution. Methods: A retrospective review of all consecutive partial nephrectomies (PN), RAPN and OPN, performed at the American University of Beirut Medical Center since the inception of the robotic program in July 2013 until July 2015. Thirty-four consecutive patients underwent PNs, 19 OPN and 15 RAPN. Preoperative variables (patient characteristics, tumor size, and RENAL score) and perioperative renal functional/patient outcomes (% change in glomerular filtration rate (GFR), ischemia time, blood loss, need for blood transfusions, total operating time, and length of hospital stay) were compared using SPSS. Results: Preoperative variables, including the size and RENAL score of the tumor were analyzed. The difference in the median size of the tumor between OPN and RAPN was not statistically significant (4.5 ± 2.7 cm vs. 3.6 ± 1.7 cm, respectively, P = 0.25). RENAL score was significantly higher for OPN compared to RAPN (7.3 ± 2.3 vs. 4.9 ± 1.5, respectively, P < 0.05). Mean operative time was significantly shorter for OPN vs. RAPN (178 ± 52 min vs. 296 ± 86 min, respectively, P < 0.05). Cold ischemia time was 24 ± 3 min in OPN, and warm ischemia time was 17.5 ± 2 min for RAPN; 10 out of the total 15 robotic cases were performed with a warm ischemia time of < 20 min. Intraoperative blood loss was comparable for both approaches (225 ± 132 mL in OPN vs. 243 ± 192 mL in RAPN), and there was no need for blood transfusions in either group. Hospital stay was significantly longer for OPN vs. RAPN (6 ± 1.6 days vs. 4 ± 0.9 days, respectively, P = 0.01). The change in GFR was comparable among both procedures (OPN = -9% vs. RAPN = -7%); pathological margin status was also comparable among both procedures, with 1/19 (5%) positive focal margins in OPN vs. 0/14 in RAPN. None of the robotic procedures required conversion to the laparoscopic or open approach. Conclusions: RAPN is currently an established approach for the treatment of kidney tumors with the advantages of decreased crude ischemia time and a shorter hospital stay, with comparable intraoperative blood loss and risk of GFR reduction. Our data show that tumor characteristics were not equivalent, with higher RENAL scores noted in patients allocated to OPN vs. RAPN, thus limiting a fair comparison of outcomes. However, the data confirm that with proper selection of patients for RAPN, outcomes were equivalent to OPN and were not jeopardized during the initial robotic learning curve. Larger prospective studies are needed to validate our results. World J Nephrol Urol. 2016;5(4):79-82 doi: https://doi.org/10.14740/wjnu286w

Despite the various treatment modalities available for patients with chronic lower urinary tract symptoms, sacral neuromodulation has proven to be a great minimally invasive option for those with refractory urinary retention, urgency incontinence, and overactive bladder symptoms. This procedure has undergone major changes since its inception in 1979, especially after the introduction of the tined lead. This chapter focuses on the complications of sacral neuromodulation and the different ways to troubleshoot them in order to improve therapeutic outcomes.