Cautery Artifact Research Articles

Cautery artifact understages urothelial cancer at initial transurethral resection of large bladder tumours.

We sought to determine how frequently cautery (thermal) artifact precludes an accurate determination of stage at initial transurethral resection of bladder tumour (TURBT) of large bladder tumours. We queried our institution's billing data to identify patients who underwent TURBT for large bladder tumours >5cm (CPT 52240) by two urologists at an academic centre from January 2009 through April 2013. Only patients who underwent initial-staging TURBT for urothelial cancer were included. Pathological reports were reviewed for stage, number of separate pathological specimens per TURBT, and presence of cautery artifact. Operative reports were reviewed for whether additional cold cup biopsies were taken of other suspicious areas of the bladder, resident involvement, and type of electrocautery. We identified 119 patients who underwent initial staging TURBT for large tumours. Cautery artifact interfered with accurate staging in 7/119 (6%) of cases. Of these, six patients underwent restaging TURBT, with 50% percent experiencing upstaging to T2 disease. Tumour size, tumour grade, whether additional cold cup biopsies were taken, number of separate pathological specimens sent, and resident involvement were not associated with cautery artifact (all p>0.05). Bipolar resection had a higher rate of cautery artifact 5/42 (12%), compared to monopolar resection 2/77 (2.6%) approaching significance (p=0.095). Cautery artifact may delay accurate staging at initial TURBT for large tumours by understaging up to 6% of patients.

Synaptophysin-Ki67 double stain: a novel technique that improves interobserver agreement in the grading of well-differentiated gastrointestinal neuroendocrine tumors

A common problem in the assessment of Ki67 proliferative index in well-differentiated gastrointestinal neuroendocrine tumors is distinguishing tumor from non-tumor. This is because background stromal lymphocytes, entrapped non-neoplastic glands, and the delicate vascular network characteristic of neuroendocrine tumors frequently contain a subset of proliferating cells. Furthermore, in small biopsies, crush and cautery artifact can alter the morphologic appearance of tumor cells, making the Ki67 proliferative index more difficult to assess. To address these issues, we developed a synaptophysin-Ki67 double stain using a commercially available immunohistochemistry kit, allowing simultaneous visualization of tumor and proliferating nuclei. To test this method, three gastrointestinal pathologists individually graded 50 gastrointestinal neuroendocrine tumors first using synaptophysin-Ki67 double-stained slides and then, after a washout period, using Ki67-only stained slides (along with routine hematoxylin- and eosin-stained slides). Interobserver agreement on Ki67 proliferative index was moderate using the Ki67-only stained slides (intraclass correlation 0.51, 95% confidence interval: 0.35–0.66) and improved using the synaptophysin-Ki67 double stain (intraclass correlation 0.79, 95% confidence interval: 0.69–0.86). Similarly, interobserver agreement on tumor grade was fair with Ki67-only stained slides (κ=0.39, P<0.001) and improved with the double stain (κ=0.58, P<0.001). Analysis of individual pathologists' scores revealed that fewer total number of tumor cells counted correlated with higher grade designation and appeared to contribute to grade discordance. In tumors cited as particularly challenging to assess by the pathologists, three of four tumors were grade discordant with the Ki67-only stain, whereas all four tumors were grade concordant with the synaptophysin-Ki67 stain. The synaptophysin-Ki67 double stain is the first technique to address specifically the histomorphologic challenges of evaluating Ki67 proliferative index in well-differentiated gastrointestinal neuroendocrine tumors. Although further validation is needed, this study provides evidence that the synaptophysin-Ki67 double stain can improve interobserver agreement.

Negative pathology after endoscopic resection of gastric epithelial neoplasms: importance of pit dysplasia.

Background/AimsEndoscopic resection (ER) is a well-established treatment modality for gastric epithelial neoplasm. However, there is a discrepancy between forceps biopsy and ER specimen pathology, including a negative pathologic diagnosis (NPD) after ER. It has been suggested that pit dysplasia (PD) is a subtype of gastric dysplasia, and the aim of this study was to assess the significance of PD in cases with NPD after ER for early gastric neoplasms.MethodsAfter ER, 29 NPD lesions that had an associated pretreatment forceps biopsy specimen, were correctly targeted during ER, and had no cautery artifact on the resected specimen were included in this study.ResultsSixteen lesions showed PD and 13 had no neoplastic pathology. The initial pretreatment forceps biopsy diagnoses of 29 NPD lesions were low-grade dysplasia (LGD) in 17 lesions, high-grade dysplasia (HGD) in seven lesions, and adenocarcinoma in five lesions, which after review were revised to PD in 19 lesions, LGD in four lesions, adenocarcinoma in two lesions, and no neoplastic pathology in four lesions. Overall, nine lesions (31%) were small enough to be removed by forceps biopsy, four NPD lesions (14%) were initially misinterpreted as neoplastic lesions, and 16 PD lesions (55%) were misinterpreted as NPD lesions on ER slides.ConclusionsApproximately half of the lesions initially diagnosed as LGD or HGD were subsequently classified as PD. Therefore, including PD as a subtype of gastric dysplasia could reduce the diagnostic discrepancy between initial forceps biopsy and ER specimens.

Comparing the Efficiency and Safety of Bipolar and Monopolar Transurethral Resection for Non-Muscle Invasive Bladder Tumors: A Systematic Review and Meta-Analysis

To evaluate the efficacy and safety of bipolar and monopolar transurethral resection of bladder tumor (TURBT) procedures for non-muscle invasive bladder cancer (NMIBC) patients. We searched for all studies investigating bipolar TURBT and monopolar TURBT for NMIBC patients in PubMed, Web of Knowledge, and the Cochrane Central Search Library. A systematic review and meta-analysis were performed. Efficacy was assessed by catheterization time, resection time, pathology, and recurrence rate. Safety was assessed by obturator nerve reflex, bladder perforation, hemoglobin decrease, and transfusion. Our searches identified eight studies. Bipolar TURBT is associated with decreased resection time, catheterization time, and hemoglobin changes. There were no statistically significant differences between bipolar TURBT and monopolar TURBT for rates of obturator nerve reflex, bladder perforation, and transfusion. The grade of cautery artifact had no different between the two procedures or even was lower in the bipolar arm. There was no significant difference in recurrence rate when comparing the two procedures. This systematic review indicates that the bipolar technique is more efficacious and safer for NMIBC patients. More large-scale, multicenter, randomized controlled studies are needed before final clinical recommendations can be made.

Electrothermal cautery artifact in a urine cytology specimen

Electrothermal cautery artifact in a urine cytology specimen

Histomorphological features of resected bladder tumors: Do energy source makes any difference.

Context:The recent advent of bipolar energy in bladder tumor resection has raised many questions regarding density of current and its effect on histopathology of the resected transurethral resection of bladder tumor (TURBT) chips.Aims:The aim of this study is to evaluate the histomorphological features in resected bladder tumors comparing bipolar versus conventional (monopolar) energy.Settings and Design:Inclusion criteria were patients with primary presentation of carcinoma urinary bladder undergoing TURBT. The patients with prior resections were excluded as these could jeopardize the results of cautery artifacts.Materials and Methods:From February 2010 to December 2011, 61 patients with primary carcinoma bladder and meeting our inclusion criteria were compared. Group 1 (n = 31) underwent bipolar-TURBT (B-TURBT) and Group 2 (n = 30) monopolar-TURBT (M-TURBT). Two pathologists, who were blinded to the form of electrocautery used, examined the resected tissue. The degree of cautery artifact in each specimen was recorded. The severity of the cautery artifact was graded as absent, mild, moderate, or severe. The mean age, tumor size, and resection time were recorded in both groups.Statistical Analysis Used:Data were analyzed using SPSS 16. Data were compared in between groups using paired t-test and Pearson's Chi-square test. The significance level was set at 0.05.Results:The mean age, tumor size, and resection time were similar in between the two groups. The pathologists had no obscurity in reaching a correct diagnosis in all cases. The cautery artifacts were graded as absent in 10 (32.2%) and 8 (26.67%), mild in 12 (38.7%) and 11 (36.67%), moderate in 5 (16.1%) and 7 (23.33%) and severe in 4 (12.9%) and 5 (16.66%) cases, respectively in Group 1 and 2. There was no statistically significant histomorphogical dissimilarity between specimens according to the type of cautery used.Conclusions:Bladder tissue obtained from B-TURBT is of equivalent histomorphological feature as that of standard M-TURBT.

Paraganglioma of the urinary bladder: a clinicopathologic spectrum of a series of 14 cases emphasizing diagnostic dilemmas.

Paraganglioma (PG) of the urinary bladder is a rare neuroendocrine neoplasm, accounting for < 0.1% of all bladder tumours. Distinction from urothelial carcinoma is imperative as management and prognosis vary markedly. In this report, we describe our experience with the histopathology of paragangliomas of the urinary bladder with emphasis on the histologic features that have led to their being misdiagnosed as conventional urothelial cancer and, most importantly, those that will help pathologists recognize this rare tumor of the bladder. All cases of PG of urinary bladder diagnosed at our institute from 2002-2012 were retrieved and diagnosis confirmed in accordance with WHO classification. Clinical and treatment details were obtained from hospital medical records. Fourteen cases of PG of urinary bladder including 5 consult cases were analysed. These included 11 transurethral resections ± partial cystectomies, 2 partial cystectomies and 1 radical cystectomy. Two out of the 5 consult cases had been submitted with a diagnosis of urothelial carcinoma and 1 with that of a rhabdomyosarcoma. Age ranged from 15-84 years (median, 43 years) with a male to female ratio of 1:2.5. Presenting symptoms were haematuria, dysuria and flank pain; only 1 case had antecedent hypertension. Histologically, typical 'zellballen' (72%), diffuse (21%) and ribbon-like (7%) growth patterns amidst a richly vascularised stroma were seen. Muscularis propria invasion and necrosis was present in 72% and 21%, respectively. Substantial cautery artifacts led to misdiagnosis in the 3 erroneous cases. Tumour cells were positive for chromogranin, synaptophysin; sustentacular cells were S-100 positive. Follow up was available in 6 patients; median follow-up was 29 months (8-120 months). One patient developed distant metastasis in cervical lymph node 10 years after diagnosis; remaining were alive without evidence of disease. Paraganglioma of the urinary bladder is a rare tumor and may be misdiagnosed as urothelial cancer especially on TURBT, but a high index of suspicion, careful search for the characteristic histological features and supportive immunohistochemical studies should lead to a correct diagnosis.

Monopolar Versus Bipolar Transurethral Resection of Bladder Tumors: A Single Center, Parallel Arm, Randomized, Controlled Trial

We compared the safety and efficacy of bipolar transurethral resection and monopolar resection for bladder tumors. A single center, parallel arm, randomized, controlled trial was performed from May 2011 to August 2012. All patients with suspected bladder tumors were eligible for study inclusion. Those who refused consent and those undergoing routine restaging transurethral resection of bladder tumor were excluded from analysis. The primary end point was the incidence of obturator jerk. Secondary study outcomes included the decrease in hematocrit, rates of recoagulation and transfusion, bladder perforation, decrease in sodium, resection syndrome and resection time. Pathological quality was assessed by comparing deep muscle and the degree of severe cautery artifact in the 2 arms. A total of 257 transurethral resections were performed during the study period. After exclusion 147 patients were randomized, including 75 in the monopolar arm and 72 in the bipolar arm. There were 6 and 4 protocol violations in the monopolar and bipolar arms, respectively. Intent to treat and per protocol analyses were performed. The incidence of obturator jerk was greater in the bipolar arm (60% vs 49.2%, p=0.27). There was no significant difference between secondary outcomes. The only significant difference was a significantly lower incidence of severe cautery artifact in the bipolar arm (25% vs 46.7%, p=0.0096). Bipolar transurethral resection of bladder tumor was not superior to monopolar resection with respect to obturator jerk, bladder perforation and hemostasis. There was a significantly lower incidence of severe cautery artifact after bipolar resection.

Endoscopic Mucosal Resection Following Liquid Nitrogen Spray Cryotherapy Yields Adequate Tissue While Expediting Treatment of Barrettʼs Esophagus

Purpose: Liquid nitrogen spray cryotherapy (LN2SC) allows for destruction of tissue in the gastrointestinal tract using a catheter-based delivery system. Prior studies have demonstrated a role for this technique in the treatment of Barrett's esophagus, esophageal cancer, gastric antral vascular ectasia, and radiation proctitis. Forceps biopsies can be obtained immediately following LN2SC treatment. However, there are no published reports to date demonstrating the ability to safely and effectively perform endoscopic mucosal resection (EMR) immediately following cryotherapy. A 66-year-old Caucasian man was referred for evaluation of iron deficiency. Six years before, he was found to have reflux esophagitis on upper endoscopy, after which he was started on esomeprazole 40 mg daily. This medication resolved his reflux and heartburn, so he did not return to gastroenterology clinic to learn that his biopsies demonstrated Barrett's esophagus with lowgrade dysplasia. Surveillance endoscopy was scheduled after resuming care, and demonstrated long-segment Barrett's (C2M5 by Prague classification). This time, pathology showed multifocal high-grade dysplasia and intramucosal adenocarcinoma. After a negative PET-CT scan and endoscopic ultrasound, plus surgical consultation, he chose LN2SC to treat his disease. At his second endoscopic cryotherapy session, two new nodules (3-4 mm and 8 mm in diameter) were found in the distal esophagus. The decision was made to complete LN2SC, then perform EMR using the band-ligator technique during the same endoscopy. Each nodule was resected separately, with minimal blood loss and no complications. Pathology again showed Barrett's esophagus with high-grade dysplasia and intramucosal carcinoma, but no invasive cancer. Well-healed EMR sites were seen without recurrence of nodularity at his next cryotherapy session 8 weeks later. To determine the efficacy of EMR post-LN2SC, an expert GI pathologist reviewed all specimens obtained by the same endoscopist using band-ligator technique over the past 2 years. She was blinded as to which specimens were obtained post-LN2SC. Both specimen size and tissue depth were similar in all reviewed samples. The only noted difference was mildly increased cautery artifact post-LN2SC. However, the pathologist was still unable to distinguish which specimens were obtained post-LN2SC compared to standard EMR technique. These data suggest that EMR can be performed successfully following LN2SC during the same endoscopic procedure, without sacrificing size or quality of the resected specimen for histopathologic analysis. Same-day treatment with both techniques can shorten time to eradication by overlapping the post-EMR and post-LN2SC recovery periods. Disclosure - Dr Smith - Consultant: CSA Medical, Inc.

The Diagnostic Utility of the Minimal Carcinoma Triple Stain in Breast Carcinomas

Pathologists are expected to accurately diagnose increasingly smaller breast carcinomas. Correct classification (ie, lobular vs ductal or in situ vs invasive) directly affects subsequent management, especially when the focus is near a surgical margin or present in a needle core biopsy and is further challenging if the lesion is morphologically ambiguous. We assessed the diagnostic utility of a multiplex, trichromogen immunostain of 3 commonly employed antibodies (CK7, p63, and E-cadherin) developed in our laboratory to evaluate these small lesions. Of the 147 specimens containing minimal (defined as ≤3 mm in size) invasive carcinoma, 81 also contained in situ carcinoma. In each case, the Minimal Carcinoma Triple Stain was prepared with a parallel H&E-stained slide. Observations of staining characteristics in the focus of interest were recorded. The Minimal Carcinoma Triple Stain was diagnostically useful in all but 1 case. In a case of invasive lobular carcinoma in an excisional biopsy, the Minimal Carcinoma Triple Stain stained only the surrounding breast tissue (appropriately) and not the focus of interest. Also, a subset of 29 of 81 excisional biopsies had minimal invasive carcinoma located 2 mm or less from the inked surgical margin, in which in all cases the Minimal Carcinoma Triple Stain was fully interpretable despite morphologic distortion due to concomitant cautery artifact and tissue disruption in some cases. The Minimal Carcinoma Triple Stain offers an accurate and tissue-conserving method to diagnose small, morphologically problematic foci of breast carcinoma while ideally leaving more tissue for additional adjunctive studies.

The “See and Treat” Strategy for Identifying Cytologic High-Grade Precancerous Cervical Lesions Among Low-Income Brazilian Women

After cytologic identification of high-grade cervical squamous intraepithelial lesions (HSILs), the most common management procedure is colposcopy-guided biopsy and endocervical curettage. The “see and treat” approach using the loop electrosurgical excision procedure (LEEP) is an alternative strategy that provides immediate and concomitant diagnosis and treatment without a previous biopsy. The see-and-treat approach may result in overtreatment in women with cervical lesions who do not require treatment or adverse effects. However, this strategy circumvents the failure to diagnose or treat HSILs and is an important strategy in low-resource and low-income settings. The see-and-treat strategy has been adopted in some states and regions in Brazil, but the possible benefits of this strategy have not been fully investigated. This retrospective study assessed the strategy of see-and-treat by LEEP for HSIL precancerous cervical lesions and evaluated post-LEEP recurrence among low-income women in Brazil. A retrospective survey of data from medical records of the Department of Gynecology, Hospital of Public Health, in União da Vitória, Paraná, Brazil, identified women who underwent LEEP for cytologic HSILs without prior biopsy between 2004 and 2008. Follow-up of patients for LEEP sample histology was performed with Papanicolaou (Pap) smear. A total of 117 women underwent LEEP for cytologic HSILs during the study period. In these women, histologic examination of tissue excised by LEEP showed that 26.7% had no lesions, and 72.6% had either histologically proven cervical intraepithelial neoplasia 2/3 (67.5%) or microinvasive/invasive carcinomas (5.2%). At follow-up, there was no significant difference in the recurrence rate between women with histologic findings of cervical intraepithelial neoplasia 2/3 and those with no lesions (16.7% and in 25%, respectively; P > 0.05). The most frequent type of recurrence (78%) was HSILs (P < 0.001). The surgical margin status among patients with cytologic HSILs was as follows: ectopositive and endopositive margins (6.3%), ectopositive margins (3.8%), and endopositive margins (33.0%). No significant difference was found in recurrence rates for women with endopositive (26.3%), no margin (17.4%), and cautery artifact margin (25.0%) involvement (P > 0.05). These findings suggest that the benefits of the see-and-treat strategy for patients with cytologic HSILs outweigh the risk of overtreatment. The data demonstrate that margin involvement should not be the only prognostic indicator. All women with both positive and negative margins on LEEP should be carefully followed.

The “see and treat” strategy for identifying cytologic high-grade precancerous cervical lesions among low-income Brazilian women

ObjectiveTo evaluate the strategy of “see and treat” by loop electrosurgical excision procedure (LEEP) for cytologic high-grade precancerous cervical lesions (squamous intraepithelial lesions; HSIL) and post-LEEP recurrence among low-income Brazilian women. MethodsIn a retrospective survey of women who underwent LEEP for cytologic HSIL without prior cervical biopsy between January 2004 and March 2008 at CISVALI, União da Vitória, Paraná, Brazil, LEEP sample histology and patient follow-up by Papanicolaou smear were assessed. ResultsAmong 117 women treated, 24% had no lesions, 67.5% had cervical intraepithelial neoplasia (CIN) grade 2/3, and 5.2% had squamous cell carcinoma or adenocarcinoma on LEEP histology. Among patients with follow-up, recurrences occurred in those with no lesions (16.7%) and CIN 2/3 (25%) (P>0.05). HSIL was the most frequent type of recurrence (87%) (P<0.001). In total, 6.3% of patients had positive ectocervical (ecto-positive) and endocervical (endo-positive) margins, 3.8% had ecto-positive, and 33.0% had endo-positive margins. Recurrences occurred in women with endo-positive (26.3%), no margin (17.4%), and cautery artifact margin (25.0%) involvement (P>0.05). ConclusionFor cytologic HSIL, the benefits of the strategy of “see and treat” by LEEP outweighed the risk of overtreatment. Patients with both positive and negative margins on LEEP should be followed carefully.

Multiphoton Microscopy in the Evaluation of Human Bladder Biopsies

Multiphoton microscopy (MPM) is a nonlinear imaging approach, providing cellular and subcellular details from fresh (unprocessed) tissue by exciting intrinsic tissue emissions. With miniaturization and substantially decreased cost on the horizon, MPM is an emerging imaging technique with many potential clinical applications. To assess the imaging ability and diagnostic accuracy of MPM for human bladder biopsies. Seventy-seven fresh bladder biopsies were imaged by MPM and subsequently submitted for routine surgical pathology diagnosis. Twelve cases were excluded because of extensive cautery artifact that prohibited definitive diagnosis. Comparison was made between MPM imaging and gold standard sections for each specimen stained with hematoxylin-eosin. In 57 of 65 cases (88%), accurate MPM diagnoses (benign or neoplastic) were given based on the architecture and/or the cytologic grade. The sensitivity and specificity of MPM in our study were 90.4% and 76.9%, respectively. A positive (neoplastic) diagnosis on MPM had a high predictive value (94%), and negative (benign) diagnoses were sustained on histopathology in two-thirds of cases. Architecture (papillary versus flat) was correctly determined in 56 of 65 cases (86%), and cytologic grade (benign/low grade versus high grade) was assigned correctly in 38 of 56 cases (68%). The MPM images alone provided sufficient detail to classify most lesions as either benign or neoplastic using the same basic diagnostic criteria as histopathology (architecture and cytologic grade). Future developments in MPM technology may provide urologists and pathologists with additional screening and diagnostic tools for early detection of bladder cancer. Additional applications of such emerging technologies warrant exploration.

Histopathology of iatrogenic injury in the colorectum

Medical interventions may cause histologic changes and injury to the colorectal mucosa. Many of these changes overlap with one another and with medical gastrointestinal disease, such as inflammatory bowel disease. This review focuses on common causes of iatrogenic injury and the histologic patterns seen on mucosal biopsies. Topics covered include: 1. Endoscopy-induced artefacts, including mucosal pseudolipomatosis, pneumatosis coli, crush and cautery artefacts, and disinfectant colitis; 2. Changes induced by surgery and other therapies, including diversion colitis, radiation colitis, and graft versus host disease; and 3. Changes induced by drugs and toxins, including melanosis coli, chemotherapy, non-steroidal-anti-inflammatory drugs, mycophenolate, kayexalate, and bowel preparations.

Utility of cytokeratin 5/6 and high-molecular-weight keratin in evaluation of cauterized surgical margins in excised specimens of breast ductal carcinoma in situ

Evaluation of the surgical margins of excision specimens for ductal carcinoma in situ (DCIS) of breast is challenging due to cautery artifact introduced in the specimen at the time of surgery. Cautery destroys the cytoarchitectural features at the tissue margins and makes the distinction between usual ductal hyperplasia (UDH) and DCIS difficult. Previous studies have shown the value of immunohistochemical staining for cytokeratin 5/6 (CK5/6) and high-molecular-weight keratin (HMWK) in distinguishing UDH from DCIS. We hypothesized that staining for CK5/6 and HMWK (34bE12) may be helpful in evaluating the cauterized surgical margins, given the 2 antibodies follow the same pattern as described in the preserved foci of the 2 entities. Forty-three excised breast specimens were stained for CK5/6 and HMWK (34bE12). Study material was divided into 5 groups: DCIS without cautery artifact, UDH without cautery artifact, UDH with cautery artifact, DCIS with mild-to-moderate cautery artifact morphologically recognizable as involving the surgical margin on hematoxylin and eosin stain, and DCIS with severe cautery artifacts precluding the evaluation of surgical margins on hematoxylin and eosin stain. A comparative evaluation of pattern, extent, and intensity of the 2 immunostains was done. Our results strongly suggest that antibodies for CK5/6 and HMWK (34bE12) may be useful in determining the presence of DCIS at surgical margins even in the event of severe cautery artifact.

Diagnostic Use of Antibody to Smoothelin in the Recognition of Muscularis Propria in Transurethral Resection of Urinary Bladder Tumor (TURBT) Specimens

Accurate recognition of muscularis propria invasion by urothelial carcinoma is vital as it serves as a crossroad between conservative and aggressive clinical management. Recently, there has been attention to the hyperplastic pattern of muscularis mucosae which may mimic the muscularis propria. We have earlier shown that smoothelin, a marker of terminally differentiated smooth muscle cells, is relatively specific for muscularis propria (positive staining) and is variably negative to weak in muscularis mucosae. The earlier study was based on cystectomy specimen slides in which the bladder cancer was not present. Pathologic staging in transurethral resection of urinary bladder tumor (TURBT) specimens is complicated by limited, unoriented, or highly cauterized samples. Herein, we test the capability of smoothelin to recognize muscularis propria in TURBT specimens to further substantiate its diagnostic applicability in routine practice. Representative sections from 70 TURBTs were immunostained with smoothelin, and muscularis propria was evaluated in H&E slides and the corresponding smoothelin immunohistochemistry slides using double-blinded analysis. In 31/70 (44%) cases, muscularis propria was involved by invasive carcinoma. Cautery artifact was present in 46/70 (66%) cases, which did not seem to affect smoothelin immunohistochemistry staining of the muscularis propria. Muscularis propria was present by H&E in 48/70 (69%) cases and 48/70 (69%) cases had muscularis propria by smoothelin immunohistochemistry-based 2 (+) or 3 (+) positivity in larger muscle bundles with round regular contours. Desmoplastic response to invasive carcinoma stained negatively for smoothelin. The sensitivity, specificity, positive predictive value, and negative predictive value of smoothelin based on comparison with morphology in TURBT specimens was 98%, 95%, 98%, and 95%, respectively. This study confirms the relatively high sensitivity and specificity for smoothelin in MP, including in TURBT specimens. Immunoreactivity is retained despite the presence of thermal tissue injury, desmoplasia, or involvement by carcinoma. Our data confirm the use of smoothelin in the accurate distinction between muscularis propria and muscularis mucosae or desmoplastic reactions, thereby facilitating appropriate pathologic stage designation in often challenging TURBT specimens.

Second Prize: A Sealed Bladder Cuff Technique During Laparoscopic Nephroureterectomy Utilizing the LigaSure™ Electrosurgical Device: Laboratory and Clinical Experience

Laparoscopic nephroureterectomy (LNU) is a safe, minimally invasive approach for management of upper tract urothelial tumors. Controversy exists over the optimal technique for the distal ureter and bladder cuff (DUBC) excision. We examined the novel technique of using the LigaSure bipolar electrosurgical device in laboratory investigations and during clinical LNU to manage the DUBC. Initial investigations were undertaken in the porcine model. Areas of both normal porcine ureters and bladders, and ex vivo human ureters from radical nephrectomy specimens were sealed with the LigaSure and stained with nicotinamide adenine dinucleotide (NADH) and hematoxylin and eosin to examine the length of treatment effect and the viability of the ablated tissue. Clinically, we performed 22 LNU for proximal urothelial tumors using the LigaSure for the management of the DUBC. Intraoperative cystoscopy assessed cuff resection and bladder leakage. On postoperative day 10, a cystogram was performed. In the porcine model, the technique sealed the bladder effectively with a mean burst pressure of 14 mm Hg. Cellular staining revealed no viable urothelial tissue in the seal area and an additional 2 mm outside this area. Eighteen patients had a successful seal/ablation intraoperatively. Cystoscopy revealed cautery artifact and blanching over the former position of the ureteral orifice. The LigaSure device ablates and seals urothelial tissue with no viable cells in the clamped and adjacent blanched tissue. Our technique is technically feasible, removes an adequate bladder cuff, typically maintains a closed urinary system, and adheres to sound oncological principles. This procedure could be performed in both laparoscopic and open nephroureterectomy for proximal upper tract transitional cell tumors.

A Comparison of Histopathologic Margin Assessment after Steel Scalpel, Monopolar Electrosurgery, and Ultrasonic Scalpel Glossectomy in a Rat Model

At the conclusion of this presentation, the participants should be able to describe the tissue effects of steel scalpel, monopolar electrosurgery, and ultrasonic scalpel glossectomy with respect to histopathologic margin assessment in a rat model. Histopathologic margin assessment is important in guiding treatment and determining prognosis for squamous cell cancer of the oral tongue. Energy based devices for glossectomy produce varying degrees of tissue distortion and artifact that can influence margin assessment. The purpose of this study is to compare the tissue effects of three surgical methods of glossectomy with respect to margin assessment by a pathologist. Blinded histopathologic study of three surgical techniques for glossectomy using a rat model. The anterior tongue of thirty Sprague-Dawley rats was excised using either steel scalpel, monopolar electrosurgery, or ultrasonic scalpel (three groups of ten). Specimens were fixed in formalin and serially sectioned, and hematoxylin and eosin stains were examined by a pathologist blinded to the surgical procedure. Comparison between surgical techniques with respect to effect on the tissue margin was carried out using a previously described grading system for margin assessment. Minimal tissue disruption at the surgical margin was produced by the steel scalpel, in contrast to monopolar electrosurgery and harmonic scalpel, which both produced varying levels of tissue distortion. Margin fragmentation, cautery artifact, and artifact depth was greater with monopolar electrosurgery when compared to harmonic scalpel. Energy based devices cause tissue distortion which may in theory effect the ability to accurately assess surgical margins for tumor involvement on histopathology. In our rat model of glossectomy, the harmonic scalpel created less tissue distortion at the surgical margin than monopolar electrosurgery. Further study is required to determine the clinical relevance of these findings.

An in vitro Study Comparing the Coagulation and Cautery Effects of Bipolar and Unipolar Cutting Modalities on Prostatic Tissue

Introduction: We aimed to compare plasmakinetic prostate resection (PKRP), plasmakinetic prostate vaporization (PKVP) and transurethral prostate resection (TURP) procedures according to cautery artifacts in tissue specimens and to compare the coagulation depths of these procedures. Materials and Methods: The prostate specimens of 10 patients that underwent open transvesical prostatectomy were used. TURP, PKVP and PKRP procedures were performed immediately. Artifactual pathological patterns that were identified in the specimens included: abnormal cellular orientation and spindling, artifactual cellular detachment from the underlying basement membrane, atypical cytological changes and stromal coagulative artifacts. The severity of cautery artifact was graded as absent, mild, moderate or severe according to the sum of points in each specimen. Results: When the groups were compared according to moderate and severe artifacts, it was observed that PKRP caused more moderate artifacts and TURP caused more severe artifacts than the other two groups (p < 0.05). The depth of the tissue affected by coagulation was 1.52 ± 1.29 mm with the TURP procedure. There were significant differences between TURP and the other two methods (p < 0.05). Conclusions: Three transurethral procedures cause cautery artifacts of varying grades. The application of TURP seems to cause more severe artifacts and PKRP and PKVP procedures seem to result in a deeper coagulation zone in the residual prostatic tissue.

Habib Laparoscopic Bipolar Radiofrequency Device: A Novel Way of Creating an Avascular Resection Margin in Laparoscopic Partial Nephrectomy

Hemostasis during the laparoscopic partial nephrectomy (LPN) is a challenge. Usually, the renal hilum is clamped to minimize blood loss. However, prolonged ischemia leads to irreversible damage. Therefore, new technology is needed to minimize blood loss while performing LPN without hilar clamping. The Habib 4x Laparoscopic device (Angio Dynamics, Queensbury, NY) is a four-pronged bipolar radiofrequency probe that is proven to reduce blood loss in laparoscopic liver resections without hilar clamping. The aim of this pilot study was to evaluate this new technology in LPN. Three patients, with exophytic renal lesions (1.1-4 cm), underwent LPN without hilar clamping, using the Habib Laparoscopic device to create an avascular resection margin. Mean operative time was 150.3 minutes, mean estimated blood loss was 100 cc, and none of the patients required transfusions. There was no significant difference between the mean pre- and postoperative serum creatinine levels (P > 0.05). All 3 resected masses were renal-cell carcinomas. Intraoperative frozen sections demonstrated negative margins in all cases. However, in the second case, with a renal lesion of 4 cm, the permanent section analysis on margins was read as focally positive. There were no complications. On follow-up imaging of up to 12 months, there were no recurrences. The Habib 4x Laparoscopic device permits the resection of exophytic renal lesions without the need for hilar clamping. However, a cautery artifact can cause difficulty in interpreting the frozen-section analysis of resection margins. Therefore, its use should be restricted to lesions of less than 2 cm.