Extirpative Surgery Research Articles

Computer-Aided Design and Manufacturing in Free Fibula Reconstruction of the Mandible: Comparison of Long-Term Outcomes with the Conventional Technique.

Pre-operative computer-aided design and manufacturing (CAD/CAM) revolutionized head and neck reconstruction after extirpative surgery. However, studies performing head-to-head comparison to the conventional technique have limited long-term follow-up. We aimed to compare short and long-term outcomes between conventional and CAD/CAM approaches for mandibular reconstruction with free fibula flaps. Patients undergoing free flap reconstruction from 2012 to 2021 were included. Data regarding patient demographics, past medical history, surgical details, complications, and reconstructive outcomes were collected. Patients who had CAD/CAM were compared with the patients who underwent reconstruction with the conventional technique. The cumulative incidence of hardware maintenance was displayed using the Kaplan-Meier method. A total of 215 patients (n=79 conventional, n=136 CAD/CAM) were included. Both cohorts had similar demographics except the CAD/CAM cohort was younger (p=0.043). The mean operative duration was 54 minutes shorter with the use of CAD/CAM (p=0.014). Total and partial flap loss rates were similar. Patients with CAD/CAM had significantly lower rates of early wound dehiscence (p=0.037). Median [interquartile range] follow-up duration was similar (931 [1854] days in conventional vs 728 [841] days in CAD/CAM, p=0.084). After excluding patients with major surgical complications in the first 30-days, CAD/CAM cohort had a lower hardware removal rate (28.8% vs 13.9%, p=0.011). The significance persisted after including only the patients with more than 2 years of follow-up. The use of preoperative CAD/CAM may reduce operative duration, while allowing for longer maintenance of hardware with reduced removal rates due to complications.

Postoperative radiotherapy after extirpative surgery may not improve survival in patients with Masaoka-Koga stage IIB thymoma: a propensity-matched study based on the SEER database

Postoperative radiotherapy after extirpative surgery may not improve survival in patients with Masaoka-Koga stage IIB thymoma: a propensity-matched study based on the SEER database

Pubic bone osteomyelitis and fistulas after radiation therapy of the pelvic region: patient-reported outcomes and urological management of a rare but serious complication

PurposeThis study investigated late urinary adverse events (UAEs) in patients who underwent pelvic radiation therapy, with a focus on occurrence, diagnostic characteristics and the impact of subsequent extirpative surgery with the need of urinary diversion on quality of life.MethodsA retrospective analysis of 20 patients after pelvic radiotherapy (2016–2022) was conducted. Data included demographics, perioperative details, oncological parameters, and patient-reported outcomes. Imaging (CT, MRI) was examined for early manifestations of late UAEs.ResultsIn the study cohort, prostate cancer was the primary malignancy in 85% with a mean radiation dose of 84 Gray over 35 days. Time to diagnosis of late UAEs was 4.0 years post-radiation. Radiological assessment demonstrated a progressive increase in typical CT and MRI features of pubic bone osteomyelitis over time. Surgical interventions, mainly cystectomy, were required with variable outcomes in patient-reported post-surgery quality of life.ConclusionDiagnosing and managing late UAEs after pelvic radiation necessitate an understanding of their occurrence, diagnostic features and appropriate management strategies. Early imaging, particularly MRI, is crucial for timely diagnosis and treatment planning. Variable post-surgery quality of life underscores the importance of a multidisciplinary approach in managing late UAEs. The study contributes to understanding these complications and emphasizes their consideration in post-radiation follow-up care.

Utilization of neoadjuvant chemotherapy for muscle-invasive bladder cancer in elderly patients: a retrospective cohort study.

Neoadjuvant chemotherapy (NAC) improves overall survival in muscle-invasive bladder cancer (MIBC). Older patients often do not receive NAC due to its potential toxicities. We examined treatment patterns of elderly MIBC patients as well as impact of NAC on survival in this population. The National Cancer Database was queried from 2006 to 2019 for stage T2-T4a MIBC patients ≥ 80years old. Treatment exposures (extirpative surgery; chemotherapy; radiation) were ascertained. Kaplan-Meier survival curves were generated based on treatment modalities (no treatment; radiation only; chemotherapy only; chemoradiation; surgery only; NAC with surgery). Multivariable Cox proportional hazards regression assessed associations with overall survival (OS). The cohort included 16,391 patients (mean age 86years); 51% received treatment. MIBC treatment was less common with advancing age; patients receiving NAC then surgery were younger and had lower comorbidity scores. From 2006 to 2019, more patients received chemoradiation, while rates of NAC rose modestly. Median OS for the NAC with surgery group was 48months versus 9months for the no treatment group. Log-rank tests showed significantly improved survival in the NAC with surgery group compared to the surgery only group, while Cox proportional hazards regression analysis showed highest survival benefit in the NAC with surgery group. Only half of elderly MIBC patients received treatment, with fewer undergoing curative intent. NAC with surgery was associated with the greatest survival benefit. While our findings should be taken in the context of potential selection bias and patient preferences, they support NAC as part of shared-decision making regardless of age.

End-Stage Kidney Disease After Partial and Radical Nephrectomy Among Patients With Severe Chronic Kidney Disease.

AUA guidelines prioritize nephron sparing in patients with preexisting chronic kidney disease (CKD). However, few studies analyze long-term renal function in patients with preoperative severe CKD who undergo extirpative renal surgery. Herein, we compare the hazard of progression to end-stage kidney disease (ESKD) following partial nephrectomy (PN) and radical nephrectomy (RN) among patients with preoperative severe CKD. Patients with stage 4 CKD who underwent PN or RN from 1970 to 2018 were identified. A multivariable Fine-Gray subdistribution hazard model was employed to assess associations with progression to ESKD accounting for the competing risk of death. A total of 186 patients with stage 4 CKD underwent PN (n = 71; 38%) or RN (n = 115; 62%) for renal neoplasms with median follow-up of 6.9 years (interquartile range 3.8-14.1). On multivariable analyses adjusting for competing risk of death, the subdistribution hazard ratio (SHR) for older age at surgery (SHR for 5-year increase 0.81; 95% CI 0.73-0.91; P < .001) and higher preoperative estimated glomerular filtration rate (SHR for 5-unit increase 0.63; 95% CI 0.47-0.84; P = .002) was associated with lower hazard of progression to ESKD. There was no significant difference in hazard of ESKD between PN and RN (SHR 0.82; 95% CI 0.50-1.33; P = .4). Among patients with preoperative severe CKD, higher preoperative estimated glomerular filtration rate was associated with lower hazard of progression to ESKD after extirpative surgery for renal neoplasms. We did not observe a significant difference in overall hazard for developing ESKD between PN and RN.

Radiation dose esclation with contact X-ray brachytherapy (Papillon) and quality of life in patients with rectal cancer: Results from the phase 3 randomised trial OPERA.

e23180 Background: Organ preservation has been increasingly offered to patients with rectal cancer as most patients wish to avoid extirpative surgery and a stoma if they have a choice. The standard of care is to offer external beam chemo radiotherapy (EBCRT) to those who are fit. OPERA (Organ Preservation in Early Rectal Adenocarcinoma) has shown improved organ preservation rate with addition of contact X-ray brachytherapy(CXB-Arm B) compared to EBCRT with EBRT boost. We evaluate whether addition od CXB boost compromise the patients Quality of Life (QOL) compared to EBRT boost and if so by how much. We report our results at 38.2 months follow up. Methods: From June 2015 to June 2020, there were 148 patients randomised of which 141 were evaluable. We used EORCT QLQ -C30, QLQ -CR29 and modified LARS score at FU visits every 3 months during FU visit 1(8 weeks)-9 (32 weeks). Results: At screening (baseline) we enrolled 126 patients (Arm A: 59, Arm B: 66). At FU -1 we received questionnaire back from 78 patients (Arm A: 35, Arm B: 43). At FU-5 there were 55 patients (Arm A:18, Arm B: 37). Finally, at FU 8 there were 43 patients (Arm A: Arm B xx). Using EORTC QOL-C30 and QOL CR-29, global QOL score for Arm A was 77.6 vs Arm B 72.22 (p = 0.14). Mean functional scale (1-5) for Arm A was 95.2 vs Arm B 92.1 (p = 0.09). Role functioning scale (6-7) for Arm A was 91.2 vs Arm B 93.18 (p = 0.57). Emotional functioning (21-24) for Arm A was 77.5 vs Arm B 73.99 (p = 0.33). Cognitive functioning (20-25) for Arm A 87.85 vs Arm B 91.92(p = 0.17). Social functioning (26-27) for Arm A 95.2 vs Arm B 92.93 (p = 0.31). Conclusions: In our analysis so far, we do not detect significant difference in QOL between Arm A and Arm B. Consider Contact x-ray brachytherapy first in patients with rectal cancer &lt; 3cm (Arm B1) which has shown higher organ preservation rate without effecting their QOL compare to EBCRT (Arm A1). Clinical trial information: NCT02505750 .

Managing complexity with chimerism: ALT-AMT flaps for complex head and neck reconstruction

BackgroundHead and neck cancer is the most common cancer in males and fifth most common in females in India. Inadequate screening programs and non-availability of local healthcare resources leads to late diagnosis and most cases present at an advanced stage. Surgical extirpation often results in complex, large defects. The concept of chimerism is useful in dealing with such extensive defects.MethodsBetween July 2013 and May 2017, all patients who underwent primary reconstruction of head and neck defects following cancer extirpative surgery, with ALT-AMT chimera flap at a tertiary care cancer centre were included in this study. The patient data of age, sex, etiology, defect size, flap size, perforator configuration, anastomotic details, donor site closure, and complications was retrospectively collected as per the designated proforma from the hospital electronic record, departmental case record forms and the first author’s personal logs, and analyzed.ResultsChimeric flaps based on the lateral circumflex femoral artery i.e. ALT plus AMT provide the desired qualities to address the complex defects. All thirteen patients had a large intraoral mucosal defect. Nine cases had a large extra oral skin defect. The average size of ALT was (112.5 cm2 area) and of AMT was (94.9 cm2 area). The combined area of ALT AMT was 28.5 X 9 = 256.5 cm2. All AMT pedicles were joining the ALT pedicle. 1 AMT was lost and all donor sites needed skin grafting.ConclusionChimeric ALT + AMT is a valuable option when complex, large, multidimensional and multicomponent defects need to be reconstructed. The advantage of utilising a single donor site and two independent flaps with a single microvascular anastomosis.Level of Evidence: Level IV, therapeutic study

Immune checkpoint inhibitors in high-grade upper tract urothelial carcinoma: Paradigm shift emphasizing organ preservation.

The aim was to evaluate the role of immune check point inhibitors (ICIs) in patients with high-grade upper tract urothelial carcinoma (UTUC) who are managed endoscopically when nephroureterectomy (NU) is not feasible, such as in patients who are either not candidates for NU or decline extirpative surgery. All patients diagnosed with high-grade UTUC and managed endoscopically between January 1996 and August 2022 were included in the study. Subsequently, patients were categorised based on their use of ICIs into group 1 (patients who did not receive ICIs) and group 2 (patients who received ICIs). Survival outcomes were assessed using Kaplan-Meier analysis, while a multivariable regression model was employed to analyse the impact of clinical characteristics on survival. A total of 29 patients were enrolled, with 14 in group 1 and 15 in group 2. Both groups exhibited similar demographic and disease characteristics, including multifocality, laterality and initial tumour size. The median follow-up period was 29.2months. Notably, group 2 demonstrated significantly enhanced overall and metastasis-free survival rates compared to group 1. At 47.8months, the overall survival rate was 0% (all patients died) in group 1, whereas it was 85.7% in group 2. Similarly, the metastasis-free survival rate was 0% (all patients had metastatic disease) in group 1 at 40.6months, whereas it reached 78.0% in group 2. The multivariable analysis indicated a correlation between ICI usage and improved survival outcomes, with a hazard ratio of 0.002. Utilisation of adjuvant ICIs in the setting of endoscopically treated patients with high-grade UTUC is associated with significantly improved survival rates. ICIs should be considered in this patient population, however, more studies with larger sample size are warranted.

The Current Status of Palliative Care, Hospice, and End-of-Life Health Care Utilization in Patients With Malignant Ureteral Obstruction.

Malignant ureteral obstruction is associated with a poor prognosis, with a median survival of 3 to 7 months. These patients are ideal candidates for concurrent palliative care services, consistent with American Society of Clinical Oncology guidelines. We aimed to characterize palliative care, hospice, and end-of-life health care utilization in patients with malignant ureteral obstruction. Patients ≥ 18 years old at our institution and diagnosed with malignant ureteral obstruction between May 2014 and August 2020 were retrospectively identified and pertinent data extracted. Palliative care, hospice, and end-of-life health care utilization was described, and factors associated with each were assessed with logistic regression models. Overall survival was assessed with Cox proportional hazard regression models. One hundred fifteen patients qualified for analysis; 39.1% (45/115) utilized palliative care and spent a median of 12.5 days (IQR 3-52 days) on nonhospice palliative care. On adjusted analysis Black ethnicity (aOR 3.44, 95% CI: 1.08-10.94) was associated with palliative care utilization. Of the patients, 53.9% (62/115) utilized hospice. The median time from hospice initiation to death was 12 days (IQR 5-23 days). On adjusted analysis, prior extirpative surgery (aOR 3.63, 95% CI 1.01-13.05) and palliative care utilization (aOR 4.38, 95% CI 1.70-11.31) were associated with hospice utilization. Median survival following diagnosis was 141 days (IQR 37.5-442.5). Of the patients, 43.0% (37/86) had high end-of-life health care utilization. On multivariable analysis, only hospice (aOR 0.03, 95% CI 0.01-0.14) was associated with less end-of-life health care utilization. Palliative care is underutilized in malignant ureteral obstruction. Hospice, but not palliative care utilization, was associated with decreased end-of-life health care utilization.

Limitations in the management of colorectal cancer in sub-Saharan Africa

Colorectal cancer (CRC) was regarded as a rare disease in native West Africans. It is now accepted as an established disease with a rising incidence. The CRC is now known to be a complex tumour with different aetiopathological pathways. With all cancers early detection is important if one aims to cure the patient. A summary of the clinical features include: Unexplained ill-health and anaemia in patients with cancer of the caecum and ascending colon; palpable abdominal mass for colon cancer; rectal bleeding and tenesmus for carcinoma of the rectum; palpable mass on digital rectal examination in at least 75% of cases. The current complete management of this disease involves extirpative surgery and adjuvant treatment with a combination of cytotoxic chemotherapy and tailored therapy. This presentation will look at ways in which seamless management of CRC in this environment is hampered. The ‘PATIENT’ factor: Ignorance (which leads to unfavourable health-seeking behaviour) Poverty (goes for all developing countries) Gullibility (under which falls religion and alternative treatment) Cultural taboos (which lead to refusal of colostomy-based treatments) Aversion of the sequelae of rectal cancer treatment especially in males where up to 30% of patients are under the age of 40 years. Late presentation (effect of 1–5) The ‘COUNTRY’ factor: Politics: inadequate budget for health Workers not enough; current brain drain of doctors, major cancer centres are stretched. Infra-structure: There is a glaring lack of any population screening programme, a lack of public enlightenment messages for awareness and only two government centres have functioning radiotherapy machines. Staplers and cytotoxic drugs have to be imported, thus are expensive and out of reach of the common man. The ‘GENETICS’ factor: The biology of CRC in the native African is different from that of Caucasians and more aggressive. Carcinomatosis peritonei is frequent. There’s also the emergence of unusual metastases to the lungs and spine, bypassing the liver. A summary of the findings by Nigerian researchers on the molecular biology of native Nigerian CRC showed MSI (Not otherwise stated) occurred in 23–53% of Nigerian CRC, MSI-H seen in 28.1–43%. KRAS in 21% while BRAF was seen in 4.5%. The significance of these results may mean that we might not be administering the right combination chemotherapy in over 50% of our patients. Some studies have shown that patients with MSI-H CRC appear to have ineffectual or even detrimental responses to 5FU-based adjuvant chemotherapy. We all know that 5FU is the cornerstone of most of the combination chemotherapy we administer to patients (FOLFOX, FOLFIRI, CapeOX, XelOX). In addition, the 2012 study on BRAF and KRAS in Nigerians by Abdulkareem et al. also suggests that Nigerian patients may benefit more from anti-EGFR therapy (Cetuximab, Panitumumab) than Caucasians. However, cost implications will make prescribing these drugs a mere academic exercise in most Nigerian patients.

The Diagnosis and Treatment Approach for Oligo-Recurrent and Oligo-Progressive Renal Cell Carcinoma.

One-third of renal cell carcinomas (RCCs) without metastases develop metastatic disease after extirpative surgery for the primary tumors. The majority of metastatic RCC cases, along with treated primary lesions, involve limited lesions termed "oligo-recurrent" disease. The role of metastasis-directed therapy (MDT), including stereotactic body radiation therapy (SBRT) and metastasectomy, in the treatment of oligo-recurrent RCC has evolved. Although the surgical resection of all lesions alone can have a curative intent, SBRT is a valuable treatment option, especially for patients concurrently receiving systemic therapy. Contemporary immune checkpoint inhibitor (ICI) combination therapies remain central to the management of metastatic RCC. However, one objective of MDT is to delay the initiation of systemic therapies, thereby sparing patients from potentially unnecessary burdens. Undertaking MDT for cases showing progression under systemic therapies, known as "oligo-progression", can be complex in considering the treatment approach. Its efficacy may be diminished compared to patients with stable disease. SBRT combined with ICI can be a promising treatment for these cases because radiation therapy has been shown to affect the tumor microenvironment and areas beyond the irradiated sites. This may enhance the efficacy of ICIs, although their efficacy has only been demonstrated in clinical trials.

Novel Use of Circulating Tumor DNA to Identify Muscle-invasive and Non–organ-confined Upper Tract Urothelial Carcinoma

BackgroundOptimal patient selection for neoadjuvant chemotherapy prior to surgical extirpation is limited by the inaccuracy of contemporary clinical staging methods in high-risk upper tract urothelial carcinoma (UTUC). ObjectiveTo investigate whether the detection of plasma circulating tumor DNA (ctDNA) can predict muscle-invasive (MI) and non–organ-confined (NOC) UTUC. Design, setting, and participantsPlasma cell-free DNA was prospectively collected from chemotherapy-naïve, high-risk UTUC patients undergoing surgical extirpation and sequenced using a 152-gene panel and low-pass whole-genome sequencing. Outcome measurements and statistical analysisTo test for concordance, whole-exome sequencing was performed on matching tumor samples. The performance of ctDNA for predicting MI/NOC UTUC was summarized using the area under a receiver-operating curve, and a variant count threshold for predicting MI/NOC disease was determined by maximizing Youden’s J statistic. Kaplan-Meier methods estimated survival, and Mantel-Cox log-rank testing assessed the association between preoperative ctDNA positivity and clinical outcomes. Results and limitationsOf 30 patients enrolled prospectively, 14 were found to have MI/NOC UTUC. At least one ctDNA variant was detected from 21/30 (70%) patients, with 52% concordance with matching tumor samples. Detection of at least two panel-based molecular alterations yielded 71% sensitivity at 94% specificity to predict MI/NOC UTUC. Imposing this threshold in combination with a plasma copy number burden score of >6.5 increased sensitivity to 79% at 94% specificity. Furthermore, the presence of ctDNA was strongly prognostic for progression-free survival (PFS; 1-yr PFS 69% vs 100%, p < 0.001) and cancer-specific survival (CSS; 1-yr CSS 56% vs 100%, p = 0.016). ConclusionsThe detection of plasma ctDNA prior to extirpative surgery was highly predictive of MI/NOC UTUC and strongly prognostic of PFS and CSS. Preoperative ctDNA demonstrates promise as a biomarker for selecting patients to undergo neoadjuvant chemotherapy prior to nephroureterectomy. Patient summaryHere, we show that DNA from upper tract urothelial tumors can be detected in the blood prior to surgical removal of the kidney or ureter. This circulating tumor DNA can be used to predict that upper tract urothelial carcinoma is invasive into the muscular lining of the urinary tract and may help identify those patients who could benefit from chemotherapy prior to surgery.

Preoperative Renal Parenchyma Volume as a Predictor of Kidney Function Following Nephrectomy of Complex Renal Masses

BackgroundThe von Hippel-Lindau disease (VHL) is a hereditary cancer syndrome with multifocal, bilateral cysts and solid tumors of the kidney. Surgical management may include multiple extirpative surgeries, which ultimately results in parenchymal volume loss and subsequent renal function decline. Recent studies have utilized parenchyma volume as an estimate of renal function prior to surgery for renal cell carcinoma; however, it is not yet validated for surgically altered kidneys with multifocal masses and complex cysts such as are present in VHL. ObjectiveWe sought to validate a magnetic resonance imaging (MRI)-based volumetric analysis with mercaptoacetyltriglycine (MAG-3) renogram and postoperative renal function. Design, setting, and participantsWe identified patients undergoing renal surgery at the National Cancer Institute from 2015 to 2020 with preoperative MRI. Renal tumors, cysts, and parenchyma of the operated kidney were segmented manually using ITK-SNAP software. Outcome measurements and statistical analysisSerum creatinine and urinalysis were assessed preoperatively, and at 3- and 12-mo follow-up time points. Estimated glomerular filtration rate (eGFR) was calculated using serum creatinine-based CKD-EPI 2021 equation. A statistical analysis was conducted on R Studio version 4.1.1. Results and limitationsPreoperative MRI scans of 113 VHL patients (56% male, median age 48 yr) were evaluated between 2015 and 2021. Twelve (10.6%) patients had a solitary kidney at the time of surgery; 59 (52%) patients had at least one previous partial nephrectomy on the renal unit. Patients had a median of three (interquartile range [IQR]: 2–5) tumors and five (IQR: 0–13) cysts per kidney on imaging. The median preoperative GFR was 70 ml/min/1.73 m2 (IQR: 58–89). Preoperative split renal function derived from MAG-3 studies and MRI split renal volume were significantly correlated (r = 0.848, p < 0.001). On the multivariable analysis, total preoperative parenchymal volume, solitary kidney, and preoperative eGFR were significant independent predictors of 12-mo eGFR. When only considering patients with two kidneys undergoing partial nephrectomy, preoperative parenchymal volume and eGFR remained significant predictors of 12-mo eGFR. ConclusionsA parenchyma volume analysis on preoperative MRI correlates well with renogram split function and can predict long-term renal function with added benefit of anatomic detail and ease of application. Patient summaryPrior to kidney surgery, it is important to understand the contribution of each kidney to overall kidney function. Nuclear medicine scans are currently used to measure split kidney function. We demonstrated that kidney volumes on preoperative magnetic resonance imaging can also be used to estimate split kidney function before surgery, while also providing essential details of tumor and kidney anatomy.

Outcomes of and indications for renal transplantation in patients with von Hippel Lindau disease

Introduction and objectiveVon Hippel-Lindau (VHL) is a hereditary cancer syndrome characterized by bilateral, multifocal renal masses. The cumulative impact of extirpative surgery can depreciate renal function and render patients anephric. In the larger end-stage renal disease population, renal transplant offers both excellent quality of life and functional renal replacement. This case control study aims to examine and compare oncologic and functional outcomes of patients who have undergone renal transplant as renal replacement therapy (RRT) to those who remain anephric. MethodsPatient charts were retrospectively reviewed of patients with germline testing confirmed VHL between 1980 and 2022 for transplant, all prior surgical history (within and outside the NCI), renal function and graft outcomes. Overall survival (OS) was determined from years after radical nephrectomy, and graft time was defined as years of graft function from initial transplant until failure or patient death. Graft survival was determined as time between transplant(s) to last follow up. Kaplan-Meier analysis was conducted to compare graft times of anephric VHL patients to those with transplanted kidneys. ResultsA total of 23 VHLD patients were identified as either anephric or candidates for transplant. Out of this cohort, 11 total VHLD received 12 total kidney grafts. Median wait time from nephrectomy to transplant was 22.6 months (IQR: 1.02–40.25 months). Median age at transplant was 32 years (IQR: 23–54 years). OS at 5 and 10 years of anephric patients who did not receive a transplant was 33% and 16.7%, respectively. OS rates of the transplant cohort at 10, 15, and 20 years were 91%, 78%, and 58% years, respectively. Median graft time was 161 months (IQR: 56–214 months). Graft survival at 10, 15, and 20 years was 69.8%, 69.8%, and 26.2%, respectively. ConclusionsWe demonstrate that transplant recipients have decreased mortality with no difference in cancer recurrence compared to those who do not receive renal transplant for RRT. This data can aid in informing providers of the optimal window for early RRT planning in VHL, while also improving patient counseling.

Pelvic Extirpative Surgery for the "End-Stage Irradiated Bladder".

Men with prostate cancer have the daunting task of selecting from multiple modalities of treatment. The long-term effects of radiation therapy are only now being recognized. For both patients and surgeons, the end-stage irradiated bladder poses numerous problems and challenges. Specifically, irradiated bladders with urosymphyseal fistula, radiation cystitis, and rectourethral fistula are challenging to manage and treat. This review outlines the presentation, workup, and management including cystectomy for these three devastating late complications of radiation therapy. There are special considerations when performing benign cystectomy that are not typically considered during oncologic cystectomy. We discuss an overview of the current literature regarding the "end-stage bladder" resulting from radiation therapy and the important considerations that must be acknowledged when managing these patients. It is shown that many of the less invasive and conservative options ultimately lead to cystectomy. Indeed, our review concludes that cystectomy with urinary diversion is a safe and viable option in select irradiated patients with the goal to improve quality of life.

The Utility of Renal Mass Biopsy in Large Renal Masses.

The role of needle core renal biopsy in large renal masses, defined as lesions larger than 4 cm, is debatable, as larger renal masses are associated with malignant histology. We aim to review the safety and impact of renal biopsy on the management of large renal masses. A retrospective, single-center review of all renal biopsies performed between January 2011 and December 2020 at Royal Perth Hospital was conducted. Indications for biopsy, complications and final management plans were correlated to assess the value of biopsies in large renal masses. In total, 126 biopsies were performed. Indeterminate imaging findings and comorbidities were the main indications for biopsies. We identified 116 (92.1%) diagnostic biopsies and 10 (8.0%) non-diagnostic biopsies due to insufficient samples or inflammatory tissue. Of the diagnostic biopsies, 99 (78.6%) were malignant and 17 (13.5%) were benign. Unnecessary extirpative surgery was avoided in 17 patients. Histology included renal cell carcinoma (96%) and other malignancies such as urothelial carcinoma (3%) and non-Hodgkin's lymphoma (1%). Benign biopsies identified histology including angiomyolipoma (35.3%) and oncocytoma (52.5%). The median follow-up time was 68 months (range 19-132 months). Renal biopsies in large renal masses may aid in preventing unnecessary surgery, especially in situations where imaging findings are equivocal or in patients with many comorbidities.

MP34-20 SEVERE POST-OPERATIVE COMPLICATIONS ARE RARE IN PATIENTS WITH URINARY-PUBIC SYMPHYSIS FISTULAE AND PUBIC BONE OSTEOMYELITIS (UPF-OM) UNDERGOING EXTIRPATIVE SURGERY; DATA FROM THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM

You have accessJournal of UrologyCME1 Apr 2023MP34-20 SEVERE POST-OPERATIVE COMPLICATIONS ARE RARE IN PATIENTS WITH URINARY-PUBIC SYMPHYSIS FISTULAE AND PUBIC BONE OSTEOMYELITIS (UPF-OM) UNDERGOING EXTIRPATIVE SURGERY; DATA FROM THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM Jordan Foreman, Kevin Krughoff, William Eward, Edward Hendershot, Christopher Mantyh, and Andrew Peterson Jordan ForemanJordan Foreman More articles by this author , Kevin KrughoffKevin Krughoff More articles by this author , William EwardWilliam Eward More articles by this author , Edward HendershotEdward Hendershot More articles by this author , Christopher MantyhChristopher Mantyh More articles by this author , and Andrew PetersonAndrew Peterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003268.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with urinary-pubic symphysis fistulae and resultant pubic bone osteomyelitis (UPF-OM) are riddled with infections prior to extirpative surgery, our prior research noted 91.7% of patients had positive bone cultures at time of surgery. Our pathway requires holding antibiotics for 2 weeks prior to surgery and not administering IV perioperative antibiotics until the bone is removed at the time of extirpative treatment. This study aims to evaluate the rates of post-operative surgical infections and complications after extirpative surgery for UPF-OM. METHODS: Using the NSQIP database, 36 patients undergoing extirpative surgery for UPF-OM were collected between 2016-2021. Pre- and post-operative characteristics and outcomes were evaluated. At our institution patients with UPF-OM undergo a standard workup and treatment pathway including MRI of pelvis confirming osteomyelitis, pre-operative nutritional labs, and optimization of modifiable risk factors. We involve a multi-disciplinary team including urology, orthopedics, infectious disease, plastic surgery, colorectal surgery if concurrent rectourethral fistula, and acute pain service. RESULTS: The median age at time of surgery was 74.32 years (68.46, 78.28). Baseline patient characteristics included history of radiation in all patients, 4 (11.11%) had a history of tobacco use within 1 year, diabetes 10 (27.78%), median albumin 3.4 (3.2, 3.6), and a median BMI of 27.1 (24.2, 30.88). The median operating room time was 371 minutes (344.5, 408) and the median length of hospitalization was 8 days (7, 10). 6 (16.7%) patients had readmissions related to surgery including 1 small bowel obstruction managed conservatively, 2 readmissions for infection, 2 for dehydration, and 1 for anemia/presyncope. No patients had a bowel anastomotic leak, ureteroenteric leak, or rectal injury. During admission no patients had surgical site infections, deep surgical site infections, urinary tract infections, or sepsis/SIRS at 48 hours. CONCLUSIONS: The rates of severe post-operative complications in extirpative surgery for UPF-OM are low. These findings are surprising given the complexity of the disease process and underlying infected/contaminated field inherent to UPF-OM. Given our pathway that withholds antibiotics until late in the extirpative procedure the rates of infection are exceedingly low and were only present at delayed readmissions. Source of Funding: Boston Scientific Fellowship Grant © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e467 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jordan Foreman More articles by this author Kevin Krughoff More articles by this author William Eward More articles by this author Edward Hendershot More articles by this author Christopher Mantyh More articles by this author Andrew Peterson More articles by this author Expand All Advertisement PDF downloadLoading ...

PD08-04 VIRTUAL RENAL MASS BIOPSY: PREDICTING RENAL TUMOR HISTOLOGY ON ABDOMINAL CT IMAGES USING MACHINE LEARNING

You have accessJournal of UrologyCME1 Apr 2023PD08-04 VIRTUAL RENAL MASS BIOPSY: PREDICTING RENAL TUMOR HISTOLOGY ON ABDOMINAL CT IMAGES USING MACHINE LEARNING Abhinav Khanna, Vidit Sharma, Adriana Gregory, H. Chase Gottlich, Cole J. Cook, Jason Klug, Christine Lohse, Theodora Potretzke, Aaron Potretzke, Stephen A. Boorjian, R. Houston Thompson, Naoki Takahashi, Bradley Erickson, John Cheville, Timothy Kline, and Bradley Leibovich Abhinav KhannaAbhinav Khanna More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Adriana GregoryAdriana Gregory More articles by this author , H. Chase GottlichH. Chase Gottlich More articles by this author , Cole J. CookCole J. Cook More articles by this author , Jason KlugJason Klug More articles by this author , Christine LohseChristine Lohse More articles by this author , Theodora PotretzkeTheodora Potretzke More articles by this author , Aaron PotretzkeAaron Potretzke More articles by this author , Stephen A. BoorjianStephen A. Boorjian More articles by this author , R. Houston ThompsonR. Houston Thompson More articles by this author , Naoki TakahashiNaoki Takahashi More articles by this author , Bradley EricksonBradley Erickson More articles by this author , John ChevilleJohn Cheville More articles by this author , Timothy KlineTimothy Kline More articles by this author , and Bradley LeibovichBradley Leibovich More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003239.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Up to 20% of renal tumors are benign and may not require treatment. However, benign versus malignant renal tumors cannot be distinguished using cross-sectional imaging. Renal mass biopsy is a possible solution, but biopsy is invasive and has notable non-diagnostic and false negative rates. As a result, many patients proceed directly to treatment, including some who undergo extirpative surgery for benign tumors. We aim to develop a radiomics and machine learning model for distinguishing between oncocytoma versus malignant renal neoplasms based on abdominal CT images. METHODS: Our institutional registry was queried for patients who underwent surgical treatment of renal tumors from 2000-2018. All surgical specimens underwent pathology re-review by an expert genitourinary pathologist. A total of 843 images from 609 patients (434 images of oncocytoma and 409 images of malignant renal tumor) were included. A previously developed artificial intelligence algorithm for segmentation of kidney, cyst, and tumor area was applied. Images were preprocessed by resampling via linear interpolation to 0.8 mm x 0.8 mm x 5 mm, window/level=440/40, and intensity normalized [0 255]. Features were extracted for the tumor region using PyRadiomics with a fixed bin width of 16. Both unsupervised (PCA, tSNE) and supervised (LR, SVM) machine learning approaches were explored. Data was split 80:20, and cross validation was used in the training/validation set parameters. The best performing model based on F1 macro was then calibrated using an isotonic calibration approach. RESULTS: Dimensionality reduction showed adequate class separation (Figure 1A). The top 10 radiomic features showed a mixture of first and second order features (Figure 1B). The final model reached an accuracy of 0.90 (Figure 1C). Of the 168 images in the testing set, only 2 benign cases were predicted to be malignant, and 15 malignant cases were predicted to be benign. The AUC for oncocytoma versus malignant histology prediction was 0.96 with CI [0.93 0.98] (Figure 1D). CONCLUSIONS: We developed a machine learning model for accurately distinguishing benign oncocytoma versus malignant renal tumors based on CT images alone. This may provide an opportunity for non-invasive risk stratification of solid renal neoplasms, which could potentially reduce overtreatment of renal tumors. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e233 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Abhinav Khanna More articles by this author Vidit Sharma More articles by this author Adriana Gregory More articles by this author H. Chase Gottlich More articles by this author Cole J. Cook More articles by this author Jason Klug More articles by this author Christine Lohse More articles by this author Theodora Potretzke More articles by this author Aaron Potretzke More articles by this author Stephen A. Boorjian More articles by this author R. Houston Thompson More articles by this author Naoki Takahashi More articles by this author Bradley Erickson More articles by this author John Cheville More articles by this author Timothy Kline More articles by this author Bradley Leibovich More articles by this author Expand All Advertisement PDF downloadLoading ...

MP31-06 SURVIVAL BENEFIT OF RENAL TRANSPLANTATION FOLLOWING COMPLETION NEPHRECTOMY IN VON HIPPEL LINDAU DISEASE

You have accessJournal of UrologyCME1 Apr 2023MP31-06 SURVIVAL BENEFIT OF RENAL TRANSPLANTATION FOLLOWING COMPLETION NEPHRECTOMY IN VON HIPPEL LINDAU DISEASE Maria Antony, Alexis Rompré-Brodeur, Aditi Chaurasia, Nikhil Gopal, Zach Kozel, Julie Solomon, Lauren Loebach, Sandeep Gurram, W. Marston Linehan, and Mark W. Ball Maria AntonyMaria Antony More articles by this author , Alexis Rompré-BrodeurAlexis Rompré-Brodeur More articles by this author , Aditi ChaurasiaAditi Chaurasia More articles by this author , Nikhil GopalNikhil Gopal More articles by this author , Zach KozelZach Kozel More articles by this author , Julie SolomonJulie Solomon More articles by this author , Lauren LoebachLauren Loebach More articles by this author , Sandeep GurramSandeep Gurram More articles by this author , W. Marston LinehanW. Marston Linehan More articles by this author , and Mark W. BallMark W. Ball More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003264.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Von Hippel-Lindau (VHL) is a hereditary cancer syndrome characterized by bilateral, multifocal renal masses. The cumulative impact of extirpative surgery can depreciate renal function and render patients anephric. In the larger end-stage renal disease population, renal transplant offers both excellent quality of life and functional renal replacement. This case control study aims to examine and compare oncologic and functional outcomes of patients who have undergone renal transplant as renal replacement therapy (RRT) to those who remain anephric. METHODS: Patient charts were retrospectively reviewed of patients with germline testing confirmed VHL between 1980-2022 for transplant, all prior surgical history (within and outside the NCI), renal function and graft outcomes. Overall survival was determined from years after radical nephrectomy, and graft time was defined as years of graft function from initial transplant until failure or patient death. Graft survival was determined as time between transplant(s) to last follow up. Kaplan-Meier analysis was conducted to compare graft times of anephric VHL patients to those with transplanted kidneys. RESULTS: A total of 23 VHLD patients were identified as either anephric or candidates for transplant. Out of this cohort, 11 total VHLD received 12 total kidney grafts. Median wait time from nephrectomy to transplant was 22.6 months (IQR: 1.02-40.25 months). Median age at transplant was 32 years (IQR: 23- 54 years). Overall survival (OS) at 5 and 10 years of anephric patients who did not receive a transplant was 33% and 16.7%, respectively. OS rates of the transplant cohort at 10, 15, and 20 years were 91%, 78%, and 58% years, respectively. Median graft time was 161 months (IQR: 56-214 months). Graft survival at 10, 15, and 20 years was 69.8%, 69.8%, and 26.2%, respectively. CONCLUSIONS: We demonstrate that transplant recipients have decreased mortality with no difference in cancer recurrence compared to those who do not receive renal transplant for RRT. This data can aid in informing providers of the optimal window for early RRT planning in VHL, while also improving patient counseling. Source of Funding: NIH MRSP © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e431 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Maria Antony More articles by this author Alexis Rompré-Brodeur More articles by this author Aditi Chaurasia More articles by this author Nikhil Gopal More articles by this author Zach Kozel More articles by this author Julie Solomon More articles by this author Lauren Loebach More articles by this author Sandeep Gurram More articles by this author W. Marston Linehan More articles by this author Mark W. Ball More articles by this author Expand All Advertisement PDF downloadLoading ...

Extended Lymph Node Sampling During Surgery for Pediatric Renal Tumors Concerning for Malignancy Does Not Increase Postoperative Complication Rates.

Although Children's Oncology Group renal tumor protocols mandate lymph node sampling during extirpative surgery for pediatric renal tumors, lymph node sampling is often omitted or low yield. Concerns over morbidity associated with extended lymph node sampling have led to hesitancy in adopting a formal lymph node sampling template. We hypothesized that complications in children undergoing lymph node sampling for renal tumors would be rare, and not associated with the number of lymph nodes sampled. A single-institution, retrospective review of patients aged 0-18 years undergoing extirpative renal surgery with lymph node sampling for a suspected malignancy between 2005 and 2019 was performed. Patients with 0 or an unknown number of lymph nodes sampled or <150 days of follow-up were excluded. A "clinically significant" complication was defined as any Clavien complication ≥III, small-bowel obstruction, chylous ascites, organ injury, or wound infection. The number of lymph nodes sampled and its influence on the odds of experiencing a clinically significant complication was examined. A total of 144 patients met inclusion criteria. Median patient age was 38 months. Twenty-one patients (15%) had a clinically significant complication, the most common of which was ileus/small-bowel obstruction (n=16). In a multivariable analysis, increased lymph node yield was not found to influence the odds of experiencing a clinically significant complication (P = .6). In this cohort, there was no statistically significant difference in clinically significant complications in patients who underwent more extensive lymph node sampling during surgery for a suspected malignant pediatric renal tumor. Future studies on protocol adherence, staging accuracy, and survival trends using a lymph node sampling template in these patients should be performed.