TOPICS OF INTEREST Percutaneous Nephrolithotomy Bleeding in Lap Partial Nephrectomy Prostate Cancer: When to use adj RT Testicular Cancer Robotic ureteroscopy and other technology GUYS 1-SINGLE STONE, SIMPLE ANATOMY
GUYS 2-MULTIPLE STONES, OR POOR LOCATION
GUYS 3-MULTIPLE STONES WITH COMPLEX ANATOMY, CALYCES DIVER TIC OR PARTIAL STAG HORN
GUYS 4- STAG HORN, OR ANY PATIENT WITH SPINA BIFIDA / SCI Guys Score for Stones GUYS SCORE/PCNL COMPLEXITY Developed for its simplicity and by reviewing literature Lots of modern studies on its validation Keys are that as Complexity increases, success rates fall and complications rise Repeat access and ancillary procedures increase with score Can provide a guide to manage patient expectations MINI PCNL Europeans love to present this My experience 10 cases, 18F sheath and flex 16F scope As perc tract size decreases so does utility of access 10F tracts discussed, IMO, too small. PCNL Mini Perc, limitation in dedicated sheaths, application in peds Discussion around Standard PCNL prone vs Modified Supine Need high selectivity of cases for supine. Many cases will need prone due to stone position and anatomy Only a few centers doing it. Advantages for anesthesia, access to urethra. Maybe for surgeons only doing PCNL Outpatient Percs, Canadian driven. Laparoscopic Partial Nephrectomy Bleeding Implications LAP PARTIAL BLEEDING
HOPKINS ALGORITHM
LAP PARTIAL BLEEDING Clamping vs No Clamping No difference Suturing of deep tissue appears to be best Delayed Bleeding (AVF vs PsuedoAn) Hopkins Algorithm, trial of observation 24hrs PARTIAL NEPHRECTOMY Simple Tumor Eneucleation Superselective microdissection Trifecta: Warm ischemia <25min/NEG Margins/No Compl 1075 matched patients Standard PN lower Margin rates vs STE PARTIAL NEPHRECTOMY Lots of studies on Clampless technique Not standard but trendy some large studies with 10year experience fascilitated by CO2 compression 12 ideal, 20 for short periods, not standardized 500 case series OR time 60min, 4cm or less, 12% complication rate, 3day stay PARTIAL NEPHRECTOMY Take aways Cold dissection of tumor fine monofilament closure of bed Sliding clip closure of defect, no need to tie knots Clamp vs clamp less is more Lap dependant Trends towards superselective micro dissection complications becoming standardized Implications for 30d anticoagulation 2% delayed bleeding higher than VTE risk all tumors less than 4cm? MONTREAL STUDY: KARAKIEWICZ ADJUVENT RT POST RRP WITH POS MARGIN IMPROVES BCR (PSA RECURRENCE) CANCER SPECIFIC SURVIVAL IS STILL CONTROVERSIAL.
7616 PTS WITH T3/T4 N0/1 PROSTATE CANCER SEER
PATH RISK SCORE T3B/GLEASON 8/LNI
IF LESS THAN 2 THEN RT DOES NOT IMPROVE MORTALITY
NNT =10 PATIENTS FOR >2 RISK FACTORS
SUGGESTS THAT MARGIN STATUS IN T3 GLEASON 7 OR LESS WITH NO LNI OR SVI, NOT INDICATIVE OF NEED FOR ADJ RT.
Prostate Cancer: When to Radiate after surgery RADS POST RAD PROSTATE
RADS POST RRP Risk Scores in development post RRP and needed given surgery for high risk disease increasing. Margin Status may be less important in decision process as compared to pathology characteristics, T3B, Gl8, LNI Do All margin pos patients need aRT? No! Biochemical DFS is not Cancer Specific Mortality Does LNI represent aggressive tumor biology or late detection? We feel T3B and high Gl Score do! Radiotherapy studies post RRP have inherent bias through inclusion of low risk scores when main criteria is margins. Only 26% or 1/4 T3 Cancers post RRP meet criteria for statistical mortality decrease with aRT with a need to treat of 10 to prevent one prostate cancer death This is from SEER database (>7000 cases)
TESTES CANCER CT threshold for nodes 4mm implications for accurately Dx stage 1 No role for PET in Non Sems Post Chemo CT 40% teratoma in NS vs 10% teratoma in sem Surveilance, and CT risk of malignancy 100mservant threshold increases risk of malig one CT 17mservant supporting post chemo surgery instead of long surveillance ROBOTIC URETEROSCOPY Development of dedicated ureteroscopy robot First introduced 2011 Increased mobility within kidney, Better flow wide angle view Infomercial