2013 Annual Meeting March 8 – 10, 2013Great Wolf Lodge Wisconsin Dells, WisconsinUrological Society, Inc.

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HOWARD B. GOLDMAN, MD, FACSCenter for Quality and Patient Safety | Glickman Urologic and Kidney InstituteThe Cleveland Clinic | Cleveland, OH

GRANVILLE LLOYD, MDUniversity of Wisconsin | Madison, WI

STEPHEN Y . NAKADA, MDChairman, Dept. of Urology

University of Wisconsin | Madison, WI

MICHAEL GURALNICK, MDMedical College of Wisconsin | Milwaukee, WI

GLENN M. PREMINGER, MDChief, Division of Urologic Surgery

Duke University Medical Center | Durham, NC

PROGRAM BOOK

Wisconsin Urological SocietyExecutive Committee

PresidentDavid R. Paolone, MD

Madison, WI

President-ElectJay I. Sandlow, MD

Milwaukee, WI

Secretary/TreasurerJohn V. Kryger, MD

Milwaukee, WI

Immediate Past PresidentJames A. Wright, MD

Fond du Lac, WI

Wisconsin Representative to NCS Board of DirectorsJohn V. Kryger, MD

Milwaukee, WI

2013 Program Planning CommitteeDavid R. Paolone, MD

John V. Kryger, MD

Executive DirectorWendy J. Weiser

Managing DirectorSue O’Sullivan

Associate DirectorMary Tully

EXECUTIVE COMMI�EEUrological Society, Inc.

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Message from the President Dear WUS Members, As president of the Wisconsin Urological Society, it is my privilege to welcome you to the annual meeting in the Wisconsin Dells, March 8 – 10, 2013. The two-day academic format has worked well the past two years, and we are continuing it for the 2013 meeting to maximize the amount of educational content provided by the meeting. Our guest speakers for the meeting are Dr. Howard Goldman from the Cleveland Clinic Foundation and Dr. Glenn Preminger of Duke University. Dr. Goldman is a specialist in female urology and will be lecturing on management of overactive bladder and surgical treatment of stress urinary incontinence. Dr. Preminger is a renowned expert on the surgical and medical management of stone disease. In addition, the academic program includes presentations from the faculty and residents of the University of Wisconsin, Madison and Medical College of Wisconsin programs. The annual meeting is at the Great Wolf Lodge in the Wisconsin Dells, and I encourage members to bring their families to the meeting to enjoy a fun-filled weekend in the “Waterpark Capital of the World.” The Welcome Reception for members on Friday night allows for reconnecting with friends and colleagues from around the state, and a casual interaction with our industry sponsors. The Annual Banquet is on Saturday night, and it allows members to be able to show off their bowling skills afterwards. This promises to be another great meeting academically and socially, and I look forward to seeing you. David R. Paolone, MD President, WUS

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About the Program Wisconsin Urological Society Residents Program The Wisconsin Urological Society recognizes the need for urology residents to network with, and be mentored by, experienced urologists in the field. To enhance their training, the WUS features presentations by residents enrolled in a Wisconsin Teaching Institution’s urology resident program. The WUS’ yearly resident podium presentations will take place on Saturday and Sunday, March 9 – March 10, during the society’s annual meeting. All urology residents in the state of Wisconsin are encouraged to submit abstracts for presentation. Topics may be clinical or basic science and cover any area in urology. All accepted abstracts are presented to the society during the general session on Saturday and Sunday. Awards will be given to best resident podium presentations from both Milwaukee and Madison. This meeting is a great opportunity to share residency training and research ideas, as well as network with urologists in the state. Disclaimer Statement Statements, opinions and results of studies contained in the program and abstracts are those of the presenters/authors and do not reflect the policy or position of the WUS nor does the WUS provide any warranty as to their accuracy or reliability. Every effort has been made to faithfully reproduce the abstracts as submitted. However, no responsibility is assumed by the WUS for any injury and/or damage to persons or property from any cause including negligence or otherwise, or from any use or operation of any methods, products, instruments, or ideas contained in the material herein. Copyright Notice Individuals may print out single copies of abstracts or slides contained in this publication for personal, non-commercial use without obtaining permission from the author or the WUS. Permission from both the WUS and the author must be obtained when making multiple copies for personal or educational use, for reproduction, for advertising or promotional purposes, for creating new collective works, for resale or for all other uses. Filming/Photography Statement No attendee/visitor at the WUS 2013 annual meeting may record, film, tape, photograph, interview, or use any other such media during any presentation, display, or exhibit without the express, advance approval of the WUS Executive Director. This policy applies to all WUS members, non-members, guests, and exhibitors, as well as members of the print, online, or broadcast media.

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Needs & Objectives Educational Needs Urologists require continuing educational enrichment to keep abreast of the developments in the field. Urology is rapidly changing and new medications, chemotherapy, surgical techniques and technology have a great impact on patient care, as well as healthcare economics. Urologists must assimilate this knowledge and make medical decisions for the best intentions of the patient. Often this translation of knowledge is facilitated by academic centers to community urologists. Specifically, urologists must be aware of emerging trends in pediatric urology, robotic surgery, prostate cancer, sexual medicine and infertility, voiding dysfunction and BPH, renal cancer and healthcare socioeconomics. Educational Objectives At the conclusion of the WUS 2013 meeting, attendees should be able to: 1. Describe the basic pathophysiology of nephrolithiasis. 2. Explain the indications and options for the medical evaluation of recurrent and first

time stone formers. 3. Identify an effective algorithm for the medical management of nephrolithiasis. 4. Explain the indications and options for the management of renal and ureteral calculi. 5. Describe the surgical techniques for ureteroscopic management of ureteral calculi. 6. Identify an effective algorithm for the management of complex renal calculi. 7. Review mechanism of action of botulinum toxin in neurogenic bladder. 8. Review indications for use of botulinum toxin in neurogenic bladder. 9. Review efficacy of botulinum toxin in neurogenic bladder. 10. Review and discuss new techniques and indications for robotically assisted surgery

in high risk prostate cancer and cystectomy. 11. Review and discuss new techniques and indications for robotically assisted surgery

in patients who have had prior surgery. 12. Explain new techniques in robotically assisted reconstructive surgery. 13. Review and discuss new techniques in robotically assisted microsurgery. 14. Analyze data pertaining to various pharmacologic and surgical treatments for

voiding dysfunction and urinary incontinence. 15. Evaluate and make informed choices regarding diagnostic work-up, testing, and

implementation of appropriate treatment strategies for overactive bladder and stress urinary incontinence.

16. Assess and manage complicated female incontinence. 17. Describe latest evidence-based data and state-of-the art care related to stress

incontinence, pelvic prolapse and pelvic reconstructive surgery. 18. Identify recent legislative bills in Wisconsin impacting urology. 19. Identify mechanisms that can be utilized by urologist to advocate for political action.

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Accreditation Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American College of Legal Medicine and the Wisconsin Urological Society. The American College of Legal Medicine is accredited by the ACCME to provide continuing medical education for physicians. The American College of Legal Medicine designates this live activity for a maximum of 9.25 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Conflict Resolution Statement The American College of Legal Medicine CME Office has reviewed this activity’s speaker and planner disclosures and resolved all identified conflicts of interest, if applicable. General Disclaimer The statements and opinions contained in this program are solely those of the individual authors and contributors and not of the Wisconsin Urological Society. The appearance of the advertisements is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality, or safety. The content of this publication may contain discussion of off-label uses of some of the agents mentioned. Please consult the prescribing information for full disclosure of approved uses. The Wisconsin Urological Society disclaims responsibility for any injury to persons or property resulting from any ideas or products referred to in the abstracts or advertisements. Special Assistance We encourage participation by all individuals. If you have a disability, advance notification of any special needs will help us better serve you. Call (847) 517-7225 if you require special assistance to fully participate in the meeting.

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General Meeting Information Registration/Information Desk Hours Location: Buffalo Phil’s Crystal Room Foyer Friday, March 8, 2013 4:30 p.m. – 7:30 p.m. Saturday, March 9, 2013 6:00 a.m. – 4:00 p.m. Sunday, March 10, 2013 7:00 a.m. – 12:00 p.m. Registration Fee Includes:

• Entrance to scientific sessions • Breakfasts/Saturday lunch • 1 ticket to the Welcome Reception

Exhibit Hall Hours Location: Brewery Saturday, March 9, 2013 7:30 a.m. – 3:15 p.m.

Evening Functions Welcome/Kick-Off Reception Date: Friday, March 8, 2013 Time: 6:30 p.m. – 7:30 p.m.

Location: Crystal Room Foyer Attire: Casual

The WUS kicks off its 2013 Annual Meeting with a Welcome Reception for arriving attendees. Members can reconnect with fellow WUS members while enjoying appetizers and drinks.

WUS Annual Banquet and Bowling Date: Saturday, March 9, 2013 Time: 6:00 p.m. – 10:30 p.m. Location: Crystal Room Attire: Casual

Join us for our WUS Annual Banquet which will be held at Buffalo Phil’s Diner located directly adjacent to the Great Wolf Lodge! Your ticket includes a full dinner buffet including drinks along with two rounds of bowling! Who will emerge as our WUS bowling champ? Be sure to bring the family and join in the fun!

ADDITIONAL TICKETS (Not included in registration fee) Welcome/Kick-Off Reception: $25 per ticket Annual Banquet: $40 per ticket for adults $25 per ticket for children 12 and under

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Program Schedule

Wisconsin Urological Society 2013 Annual Meeting March 8 – March 10, 2013

Great Wolf Lodge Wisconsin Dells, Wisconsin

*All sessions will be located at Buffalo Phil’s Grill unless otherwise noted

FRIDAY, MARCH 8, 2013 4:30 p.m. – 7:30 p.m. Registration/Information Desk Hours Location: Crystal Room Foyer 5:00 p.m. – 6:30 p.m. WUS Board of Directors Meeting Location: Cub 1 at the Great Wolf Lodge 6:30 p.m. – 7:30 p.m. Welcome/Kick-Off Reception Location: Crystal Room Foyer SATURDAY, MARCH 9, 2013 6:00 a.m. – 4:00 p.m. Registration/Information Desk Hours Location: Crystal Room Foyer 7:00 a.m. – 8:00 a.m. Continental Breakfast Location: The Brewery 7:30 a.m. – 3:15 p.m. Exhibit Hall Open Location: The Brewery 6:00 p.m. – 10:30 p.m. WUS Annual Banquet and Bowling Location: Buffalo Phil’s Dinner served in the Crystal Room 8:00 a.m. – 8:05 a.m. Welcome – Introduction

David Paolone, MD WUS President University of Wisconsin Madison, WI

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8:05 a.m. – 9:00 a.m. SESSION 1: STONE DISEASE PODIUM Moderator: Bruce Neal, MD

8:05 a.m. – 8:12 a.m. ABSTRACT #1 Does Preoperative Stenting, Anesthesia and Stone Size Impact Insitu Treatment of Lower Pole Stones? Sri Sivalingam, Priyanka D. Sehgal, Sara L. Best, Stephen Y. Nakada Madison, WI Presenter – Sri Sivalingam, MD

8:12 a.m. – 8:19 a.m. ABSTRACT #2

Higher Risk of Uric Acid Stone in the Obese (BMI 30-35) and Severely Obese (BMI >30) Aaron M. Potretzke, Sri Sivalingam, Priyanka D. Sehgal, Kristina L. Penniston, Stephen Y. Nakada Madison, WI Presenter – Aaron M. Poetretzke, MD

8:19 a.m. – 8:26 a.m. ABSTRACT #3

Current Practices in Percutaneous Nephrolithotomy Among Endourologists Sri Sivalingam, Shannon T. Cannon and Stephen Y. Nakada Madison, WI Presenter – Shannon Cannon

8:26 a.m. – 8:32 a.m. ABSTRACT #4

Higher Hemoglobin A1C is Associated with a Greater Likelihood of Uric Acid Stone Formation: Is Control of Diabetes Important for Stone Prevention? Sara L. Best, Jonathan M. Shiau, Rachel Bell, Kristina L. Penniston Madison, WI Presenter – Jonathan M. Shiau, MD

8:32 a.m. – 8:39 a.m. ABSTRACT #5

Skin-to Stone Distance (SSD) and Hounsfield Unit Density (HUD) are Preserved Using Ultra-Low Dose Computerized Tomography (CT) in Patients with Urolithiasis Jennifer E. Heckman, Meghan G. Lubner, Matthew Houlihan, Perry J. Pickhardt, Stephen Y. Nakada Madison, WI Presenter – Jennifer E. Heckman, MD

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8:39 a.m. – 8:46 a.m ABSTRACT #6 Calcium Oxalate Lithiasis Induces Renal Tubular Injury and Fibrosis in a Porcine Model of Nephrolithiasis Sri Sivalingam, Kristina L. Penniston, Priyanka D. Sehgal, Thomas D. Crenshaw and Stephen Y. Nakada Madison, WI Presenter – Sri Sivalingam, MD

8:46 a.m. – 8:53 a.m. ABSTRACT #7

10-Year Single Center Experience with Chronic Ureteral Stent Placement for Malignant Obstruction – Assessment of Long-Term Durability Jennifer E. Heckman, Jason Carr, Stephen Y. Nakada Madison, WI Presenter – Jennifer E. Heckman, MD

8:53 a.m. – 9:00 a.m. ABSTRACT #8

Patient Education and the Impact on Ureteroscopy Experience Nathan D. Grunewald, Alison R. Marciniak, Carley M. Davis, MD Milwaukee, WI Presenter – Nathan D. Grunewald, MD

9:00 a.m. – 9:10 a.m. Questions/Discussion 9:10 a.m. – 9:50 a.m. Practical Advice for Medical Stone Management

Glenn M. Preminger, MD Chief, Division of Urologic Surgery Duke University Medical Center Durham, NC

9:50 a.m. – 10:00 a.m. Questions/Discussion

10:00 a.m. – 10:21 a.m. SESSION 2: SEXUAL MEDICINE / FERTILITY

PODIUM Moderator: Jay Sandlow, MD

10:00 a.m. – 10:07 a.m. ABSTRACT #9 Impact of Male Age on Pregnancy Rates After Bilateral Vasovasotomy Anand Shridharani, Donald Neff, Gabriel Fiscus, and Jay I. Sandlow Milwaukee, WI Presenter – Donald Neff, MD

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10:07 a.m. – 10:14 a.m. ABSTRACT #10 Management of Peyronie’s Disease within the NCSAUA as Assessed by E-mail Survey Octavia N. Devon, Daniel H. Williams, IV, David R. Paolone, MD Madison, WI Presenter – David R. Paolone, MD

10:14 a.m. – 10:21 a.m. ABSTRACT #11

90 Urological Management of Fertility Options Following Previous Vasectomy: Analysis of Current Practice Ola Blach, Anand Shridharani, Ira Sharlip, Arnold Belker, Jay Sandlow Milwaukee, WI Presenter – Anand Shridharani, MD

10:21 a.m. – 10:31 a.m. Questions/Discussion 10:31 a.m. – 10:50 a.m. Break with Exhibitors Location: The Brewery 10:50 a.m. – 11:15 a.m. The Use of Botulinum Toxin in Neurogenic Bladder

Michael Guralnick, MD Medical College of Wisconsin Milwaukee, WI

11:15 a.m. – 11:25 a.m. Questions/Discussion 11:25 a.m. – 11:50 a.m. Update on New Accreditation System

Stephen Y. Nakada, MD Chairman, Dept. of Urology University of Wisconsin Madison, WI

11:50 a.m. – 12:00 p.m. Questions/Discussion 12:00 p.m. – 1:15 p.m. Lunch in the Exhibit Hall Location: The Brewery 1:15 p.m. – 2:00 p.m. Surgical Rx of Urolithiasis: An Evidence-Based

Approach Glenn M. Preminger, MD

Chief, Division of Urologic Surgery Duke University Medical Center Durham, NC

2:00 p.m. – 2:10 p.m. Questions/Discussion

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2:10 p.m. – 2:35 p.m. Frontiers in Robotic-Assisted Surgery Granville Lloyd, MD

University of Wisconsin Madison, WI

2:35 p.m. – 2:45 p.m. Questions/Discussion 2:45 p.m. – 3:15 p.m. Break with Exhibitors

Location: The Brewery 3:15 p.m. – 3:57 p.m. SESSION 3: BLADDER CANCER PODIUM Moderator: Sara Best, MD

3:15 p.m. – 3:22 p.m. ABSTRACT #12 BCG-Induced Depletion of Intracellular ATP in Human Urothelial Carcinoma Cell Lines Bryan Sack, Gopitkumar Shah, Gang Cheng, Jacek Zielonka, Balaraman Kalyanaraman, William See Milwaukee, WI Presenter – Bryan Sack, MD

3:22 p.m. – 3:29 p.m. ABSTRACT #13

Leukemoid Reaction: A Rare Paraneoplastic Syndrome in Urothelial Cancers Associated with a Grave Prognosis Daniel D. Shapiro, Kelvin Wong, E. Jason Abel, Tracy M. Downs Madison, WI Presenter – Daniel Shapiro

3:29 p.m. – 3:36 p.m. ABSTRACT #14

BCG Induces Oxidative Stress as Demonstrated by Lipid Peroxidation in Human Urothelial Carcinoma Cell Lines Gina M. Lockwood, Fanhong Chen, William A. See Milwaukee, WI Presenter – Gina Lockwood, MD

3:36 p.m. – 3:43 p.m. ABSTRACT #15

Preoperative Neutrophil Lymphocyte Ratio (NLR) Correlates with Tumor Stage and Tumor Grade Found at the Time of Transurethral Resection of Bladder Tumors Daniel D. Shapiro, Aaron Potretzke, Muta M. Issa, Luke Hillman, Ryan W. Dobbs, Viraj Master, E. Jason Abel, Daniel Canter, Tracy M. Downs Madison, WI Presenter – Daniel Shapiro

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3:43 p.m. – 3:50 p.m. ABSTRACT #16 BCG Treatment of Human Urothelial Carcinoma Cells Induces Oxidative DNA Damage Scott C. Johnson, Fanghong Chen, William A. See Milwaukee, WI Presenter – Scott C. Johnson, MD

3:50 p.m. – 3:57 p.m. ABSTRACT #17 Ketamine Based Multimodal Analgesia Decreases time to Bowel Movement and Discharge after Robotic-Assisted Cystectomy and Urinary Diversion Tanya D. Davis, Robert J. Schlosser, Kenneth M. Jacobsohn, Peter Langenstroer, William A. See, John Tlachac, Karin Madsen Presenter – Tanya D. Davis, MD

3:57 p.m. – 4:04 p.m. Questions/Discussion SUNDAY, MARCH 10, 2013 7:00 a.m. – 8:00 a.m. Breakfast Location: Crystal Room Foyer

7:00 a.m. – 12:00 p.m. Registration/Information Desk Hours Location: Crystal Room Foyer 8:00 a.m. – 8:05 a.m. Welcome – Introduction

David Paolone, MD WUS President University of Wisconsin Madison, WI

8:05 a.m. – 8:33 a.m. SESSION 4: PEDIATRIC UROLOGY PODIUM

Moderator: Bruce Slaughenhoupt, MD

8:05 a.m. – 8:12 a.m. ABSTRACT #18 Enhancing the Therapeutic Benefit of Deflux for Vesico-Ureteral Reflux with Adjunctive Therapies Morgan K. Prince, Anthony H. Balcom Milwaukee, WI Presenter – Morgan Prince

8:12 a.m. – 8:19 a.m. ABSTRACT #19

Management of Feminizing Testis Tumors in Prepubertal Boys Justin O. Benabdallah, Patricia Donohoue, Anthony H. Balcom, MD Milwaukee, WI Presenter – Justin O. Benabdallah, MD

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8:19 a.m. – 8:26 a.m. ABSTRACT #20 A Retrospective Study of Urolithiasis, Obesity, and other Potential Predictors in a Midwestern, Pediatric Population John T. Roddy, Anas I. Ghousheh, Melissa A. Christensen, Laura D. Cassidy, John V. Kryger, MD, Charles T. Durkee Milwaukee, WI Presenter – John Roddy

8:26 a.m. – 8:33 a.m. ABSTRACT #21

Is There a Need for Preoperative Ureteral Stenting in Pediatric Patients Undergoing Ureteroscopy? Dane P. Johnson, Ruth Swedler, Charles Durkee, Travis Groth Milwaukee, WI Presenter – Dane Johnson, MD

8:33 a.m. – 8:43 a.m. Questions/Discussion 8:43 a.m. – 9:20 a.m. North Central Section Visiting Professor

Evaluation and Management of Complications of Stress Urinary Incontinence Surgery Howard B. Goldman, MD, FACS

Center for Quality and Patient Safety Glickman Urologic and Kidney Institute The Cleveland Clinic Cleveland, OH

9:20 a.m. – 9:30 a.m. Questions/Discussion 9:30 a.m. – 10:19 a.m. SESSION 5: PROSTATE/KIDNEY PODIUM

Moderators: John V. Kryger, MD Scott Klein, MD

9:30 a.m. – 9:37.a.m. ABSTRACT #22

Laparoscopic Cryoablation for Clinical Stage T1 Renal Masses: Long-Term Oncological and Functional Outcomes at The Medical College of Wisconsin Khanh Pham, Frank Begun, Kenneth Jacobsohn, William A. See, Peter Langenstroer, MD Presenter – Khanh N. Pham, MD

9:37 a.m. – 9:44 a.m. ABSTRACT #23

Comparative Analysis of Tissue Biomarkers and Prognostic Systems to Predict Post Surgical Recurrence in Renal Cell Carcinoma Patients Tyler Bauman, Kelvin Wong, FangFang Shi, David Jarrard, Tracy Downs, Wei Huang, E. Jason Abel Madison, WI Presenter – Tyler Bauman

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9:44 a.m. – 9:51 a.m. ABSTRACT #24 Safety and Feasibility of Percutaneous Microwave Ablation for Renal Parenchmal Tumors Kelvin S. Wong, Sara L. Best, Anna J. Moreland, Timothy J. Ziemlewicz, J. Louis Hinshaw, Fred T. Lee, Jr., Christopher L. Brace, Meghan G. Lubner, Marci L. Alexander, Stephen Y. Nakada, E. Jason Abel Madison, WI Presenter – Kelvin Wong, MD

9:51 a.m. – 9:58 a.m. ABSTRACT #25 Multiphoton Microscopic Characterization of Renal Cell Carcinoma Sara L. Best, E. Jason Abel, and Kevin W. Eliceiri Madison, WI Presenter – Sara L. Best, MD

9:58 a.m. – 10:05 a.m. ABSTRACT #26 Development of Multi-Institutional Validation of an Upgrading Risk Tool for Biopsy Gleason 6 Prostate Cancer Matthew Truong, Jon A. Slezak, Chee Paul Lin, Viacheslav Imremashvili, Martins Sado, Aria A. Razmaria, Glen Leverson, Mark Soloway, Scott Eggener, Edwin J. Abel, Tracy M. Downs, and David F. Jarrard Presenter – Matthew Truong, MD

10:05 a.m. – 10:12 a.m. ABSTRACT #27

Novel Nomogram for Risk Stratification in Patients Considering Active Surveillance for Low-Risk Prostate Cancer Jonathan M. Shiau, Matthew Truong, Jon Slezak, David F. Jarrard Madison, WI Presenter – Jonathan M. Shiau, MD

10:12 a.m. – 10:19 a.m. ABSTRACT #28

Robotic Simple Prostatectomy Alex Zacharias, Mark Dykstra, Sameer K. Sharma, Michael J. Krco Grafton, WI Presenter – Alex Zacharias, MD

10:19 a.m. – 10:29 a.m. Questions/Discussion

10:29 a.m. – 10:40 a.m. Break

10:40 a.m. – 10:55 a.m. Wisconsin Legislative Update Ross Weber

10:55 a.m. – 11:00 a.m. Questions/Discussion

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11:00 a.m. – 11:40 a.m. North Central Section Visiting Professor Management of the Patient with Refractory Overactive Bladder Howard B. Goldman, MD, FACS

Center for Quality and Patient Safety Glickman Urologic and Kidney Institute The Cleveland Clinic Cleveland, OH

11:40 a.m. – 11:50 a.m. Questions/Discussion 11:50 a.m. – 12:11 p.m. SESSION 6: BIZZARE & INTERESTING UROLOGY CASES

Moderator: Adam C. Tierney, MD

11:50 a.m. – 11:57 a.m. ABSTRACT #29 Epsilon Aminocaprioic Acid for the Treatment of Refractory Upper Tract Hematuria in a Patient with Medullary Sponge Kidney Dustin A. Pagoria, Peter Langenstroer Milwaukee, WI Presenter – Dustin Pagoria, MD

11:57 a.m. – 12:04 p.m. *ABSTRACT #30

Pure Adult Yolk Sac Tumor of the Testis Presenting with Scrotal Violation: An Interesting Case Amul M. Shah, Jay I. Sandlow, Gary Sudakoff, Anand N. Shridharani, MD Presenter – Amul M. Shah, MD

*Not CME Accredited 12:04 p.m. – 12:14 p.m. Questions/Discussion 12:15 p.m. – 12:45 p.m. Annual Business Meeting 12:45 p.m. Meeting Adjourned

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Abstracts

ABSTRACT #1 Does Preoperative Stenting, Anesthesia and Stone Size Impact Insitu Treatment of Lower Pole Stones? Sri Sivalingam, Priyanka D. Sehgal, Sara L. Best, Stephen Y. Nakada Madison, WI Introduction and Objectives: Our objective was to evaluate preoperative stenting and stone size on in-situ ureteroscopic treatment of lower pole renal calculi, and whether endotracheal intubation (ETT) vs laryngeal mask airway (LMA) yielded any differences in outcomes. Methods: After institutional research ethics approval, retrospective review was conducted for all ureteroscopic stone procedures between 2005 to 2009 performed. Factors evaluated included demographic information, stone size, location, pre-operative stent placement, type of anesthesia, procedural details, and outcomes including success rates (SR), operative times and complications. The goal of ureteroscopy was to fragment stones to completion. SR was defined as residual fragments < 4mm, and was based on post-operative KUB imaging. Results: 449 patients who underwent ureteroscopic lithotripsy were reviewed, and the results were filtered to include only those treated for lower pole calculi by a single surgeon. 79 patients were included in the final analysis (42 males, 37 females, p=0.80). All stones in this subset were treated in-situ in the lower pole location using a 270 micron laser fiber, without stone distraction or fragment extraction. 62 (78%) patients were not pre-stented, while 17 (22%) patients were pre-stented. 52 (66%) patients had ETT and 27 (34%) had LMA. There were no differences in gender (P=0.29), stone size (P= 0.29) or laterality (P=0.055) between groups. Overall SR was 72%; the SR was significantly higher for stones <10mm vs >10mm (83.3% vs 58%, respectively; P=0.012). There were no differences in SRs between the non pre-stented vs pre-stented groups (73% vs 71%, respectively; P=1.0), or in the ETT vs LMA groups (69.2% vs 78%, respectively; P=0.60). The SR of left vs right-sided procedures was 67% vs 79%, respectively (P=0.3). Mean operative time was 50.1 min, with significantly shorter operative times in the non- stented group (46.4 min vs 65.1 min, P=0.003), and no difference in the ETT vs LMA group (52 min vs 45.3 min, respectively, P=0.19). No major complications were observed in either group; symptomatic UTI’s in the non-prestented vs pre-stented groups was 4% vs 10.5%, respectively (P=0.29). Conclusions: We observed 83% SRs for stones <10mm compared to 58% in stones >10mm after in situ ureteroscopy for lower pole renal calculi. We did not find an advantage with pre-operative stent placement with respect to SRs, operative times, or complication rates. Additionally, we did not observe any benefits in using ETT over LMA, suggesting LMA controlled anesthesia might be sufficient for the treatment of lower pole stones.

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ABSTRACT #2 Higher Risk of Uric Acid Stone in the Obese (BMI 30-35) and Severely Obese (BMI >30) Aaron M. Potretzke, Sri Sivalingam, Priyanka D. Sehgal, Kristina L. Penniston, Stephen Y. Nakada Madison, WI Introduction and Objectives: We sought to identify correlations between body mass index (BMI), a calculation of body weight for height, and stone composition, with particular emphasis on obesity (BMI >30) and severe obesity (BMI >35). Methods: Retrospective review of patients who were managed in our stone clinic and who had available stone composition data was performed between March 2006 and Sept 2010 with IRB approval; patients without BMI data were excluded. Patients were grouped by BMI: 18.5-24.9 (normal), 25-29.9 (overweight), 30-34.9 (class I obesity) 35-40 (class II obesity) and >40 (class III obesity). Stone type was defined by the predominant stone component (>50%); and grouped as calcium oxalate (COM and COD); uric acid (UA), calcium phosphate (including brushite), cystine, and other. Results: 408 patients were included in the analysis, with a mean BMI of 28.70 (SD 7.93). In our cohort, 44% were female with mean age 47 yrs (SD 19.43), and mean BMI 28.7 (SD 8.12); 56% were male with mean age 54.3 yrs (SD 17.9), and mean BMI 28.7 (SD 7.81). BMI was as follows: normal BMI (29%), overweight (29%), class I obesity (18%), class II obesity (15%) and class III obesity (9%). Mean BMI in the study cohort was 28.70 (SD 7.93). There was a trend for a relationship between BMI and any stone type (P=.061). In those with UA stones, a positive correlation with BMI was observed (P=0.0008), with a four-fold higher risk of UA stones in all classes of obese patients compared to the overweight (12% and 11.5% vs. 3%, respectively). BMI was inversely correlated with calcium phosphate stones (P=0.006). Of the comorbidities we examined, i.e. gout, diabetes, bowel disease, coronary artery disease, hyperparathyroidism, and recurrent urinary tract infections, there was a significant association between diabetes and UA stones (P=0.006). Moreover, there was significant association between age and stone type (P=0.02) with specific age associations for UA (P=0.04) and CaPO4 stones (P=0.006). More than 75% of UA stone formers were between 50-70 yrs, and the risk for UA stones was higher in those >50 yrs vs. <50 yrs (8.6% vs. 1.7%, respectively, P=0.041). Conclusions: The prevalence of UA stones was highest in obese patients. Obesity of any degree confers an increased risk for UA stones, and as such, medical management for obese stone formers should include lifestyle modifications, and the treatment and prevention of obesity in stone formers should be prioritized.

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ABSTRACT #3 Current Practices in Percutaneous Nephrolithotomy Among Endourologists Sri Sivalingam, Shannon T. Cannon and Stephen Y. Nakada Madison, WI Introduction and Objectives: Our objective was to characterize current practices among endourologists to quantify variations in procedural techniques in relation to practice setting, experience and fellowship training. Methods: A web-based survey was administered to active endourological society members. Responses were grouped based on demographic information pertaining to setting of practice, number of years practiced and fellowship training in endourology. PCNL technique details were evaluated and compared by each group. Statistical analysis was performed using SPSS. Results: 293 completed responses of 2000 were received. There was a significant difference in the experience level among respondents (P<0.001), with a relatively greater proportion being 11-20 years in practice. The majority of respondents were academic urologists (74%), with 18% being within a group-based private practice. 77% of respondents obtained their own access while 19% had access by interventional radiologists; this was similar across all practice settings and experience levels. 62% were endourology fellowship trained, and fellows were significantly more likely to obtain their own access (82% versus 71%, p=0.022). 86% used the prone position to obtain access, 10% used supine and 4% used lateral decubitus. An antegrade approach was preferred by 68%, while 18.5% used a retrograde, and 12% used a combined approach. These trends held true across all demographic sub-groups. Overall, 76% placed a nephrostomy tube for post-operative drainage; a ureteral stent or catheter was left in place by 28% or 11% of respondents, respectively, and only 6 respondents (2%) performed a “tubeless” procedure without any drainage. Urologists in practice >20 years were less inclined to use ureteral catheters compared to those in practice <20 years (5% vs 13%, p=0.007) for post operative drainage. Conclusions: The majority of endourologists performing PCNLs who responded obtain their own access, and there is an even higher proportion of self-obtained access in endourology fellowship trained urologists. Prone positioning is predominant, tubeless approaches are rare, and more than 75% of respondents leave a nephrostomy tube post-operatively.

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ABSTRACT #4 Higher Hemoglobin A1C is Associated with a Greater Likelihood of Uric Acid Stone Formation: Is Control of Diabetes Important for Stone Prevention?Sara L. Best, Jonathan M. Shiau, Rachel Bell, Kristina L. Penniston Madison, WI

Objective: Patients with diabetes mellitus (DM) are known to have a propensity for lower urine pH and a higher prevalence of uric acid calculi. However, as not all stone forming patients with DM form uric acid stones, other factors may be contributory. Glycemic control in diabetics varies due to factors such as compliance with nutritional, exercise, and pharmacologic regimens. The impact of glycemic control on stone composition, however, is unknown. We examined the influence of hemoglobin A1c (HgbA1c), a measure of long-term DM control, on stone composition.Methods: Using an approved institutional database, we performed a retrospective chart review of 540 stone formers and extracted clinical characteristics known to be associated with stone formation. We also collected data on DM management and HgbA1c measures to assess glycemic control in diabetics. Patients’ stone types were categorized based both on predominant (>50%) composition and on the subtype (any uric acid, any brushite, or >5% calcium phosphate). Variables were compared using Fisher’s exact tests and ANOVA.Results: In our cohort, we confirmed that stone formers with DM (n=107) were more likely to have ≥50% uric acid stones than patients without DM (20% and 5% respectively, p < 0.0001) and less likely to have brushite stones (0% in DM, 4% in non-DM, p = 0.019). In analyzing subtype stone compositions (<50%), patients with stones containing any uric acid had higher mean HgbA1c than those with pure CaOx calculi (5.9% vs 6.7%, p = 0.02, Figure 1). Patients whose diabetes was managed with oral hypoglycemic medications had more uric acid stones than those managed with other strategies (34% vs 10%, p=0.005) and this may reflect poorer diabetes control in patients prescribed oral medications (mean HgbA1c 7.3% vs 6.2%, p < 0.0001).Conclusions: Our study corroborates others suggesting that diabetic stone formers are more likely to form uric acid stones than the general stone forming population. Uric acid stones should be suspected in patients with DM and especially those with high HgbA1c. Our study suggests that better glycemic control may reduce the likelihood of uric acid nephrolithiasis and supports the inclusion of diabetes control as a component of the multidisciplinary medical management of stone forming patients.

Figure 1: Mean HgbA1c (normal 4.3-6.0%) in patients with various stone types

p=p=

Nor

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ABSTRACT #5 Skin-to Stone Distance (SSD) and Hounsfield Unit Density (HUD) are Preserved Using Ultra-Low Dose Computerized Tomography (CT) in Patients with Urolithiasis Jennifer E. Heckman, Meghan G. Lubner, Matthew Houlihan, Perry J. Pickhardt, Stephen Y. Nakada, Madison, WI Objectives: The objective of this study was to ascertain whether ultra-low dose CT (abdominal x-ray level exposure) is comparable to standard dose flank pain CT with regard to measurements of SSD and HUD of stones. Methods: We performed a prospective analysis of patients with history of urinary calculi. Clinicopathologic data, including age, gender, BMI, calculus laterality, and calculus location were examined. All patients underwent standard dose flank pain CT, and ultra-low dose CT (70-90% dose reduction) was performed immediately thereafter. All images were reviewed by a board certified abdominal fellowship trained radiologist. Calculus characteristics, including SSD and HUD, were measured on both standard and ultra-low dose images. Measurements on images at each radiation dosage were compared using paired t-tests and determination of mean absolute difference. Results: Eighteen patients with history of urinary calculi were evaluated in this series. Mean patient age was 54.7 years (30-81), and mean BMI was 27.7 kg/m2 (16.1-39.1). Fifteen of 18 patients (83%) had evidence of urinary calculus on imaging. Of patients with urolithiasis, 60% had left-sided calculi and 40% had right-sided calculi. Urinary calculus was renal in 13 patients (87%) and located in the distal ureter in the remaining two patients. There was no difference in measurement of SSD (p = 0.96) or HUD (p = 0.95) on ultra-low dose CT as compared with standard flank pain CT. On average, absolute differences in SSD and stone attenuation as measured on ultra-low dose as compared with standard dose CT were 0.25 cm and 58 HU respectively. Mean effective radiation dose was significantly lower on ultra-low dose CT as compared with standard CT (1.5 mSv and 7.8 mSv respectively, p <0.05). Conclusions: Among patients with urinary calculi undergoing evaluation with CT, our study demonstrates preservation of important patient and calculus measurements on ultra-low dose CT. Given the significantly lower radiation dose that ultra-low dose CT confers, this represents a novel approach to imaging in calculus disease with lower risk to the patient.

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ABSTRACT #6 Calcium Oxalate Lithiasis Induces Renal Tubular Injury and Fibrosis in a Porcine Model of Nephrolithiasis Sri Sivalingam, Kristina L. Penniston, Priyanka D. Sehgal, Thomas D. Crenshaw and Stephen Y. Nakada Madison, WI Introduction and Objectives: We have previously reported hyperoxaluria and calcium oxalate calculi in adult sows fed hyroxyproline (HP). The purpose of this study was to grossly and histopathologically characterize intra-renal effects in this paradigm. Methods: With institutional animal care approval, we maintained 18 pregnant sows in the swine facility at our campus. Treatment was allocated to 14 sows (10% HP mixed with regular dry feed), and 4 were maintained on standard feed with an equal amount of starch (200 g) was mixed (controls). Nine animals were euthanized at 21 d (3 control, 6 HP). All kidneys were extracted and examined in a blinded manner for gross appearance and for CT evidence of stones (GE scanner, 80kV, 400MA, 1 sec rotation, 0.625mm slices). Papillary and cortical samples were processed with H&E, Yasue, and PAS stains for histologic analysis. Results: Control animals were normal in gross appearance. Treated sow kidneys showed significant calculi distributed within renal papilla on CT, and grossly appeared mottled in the renal cortex and papillary areas; cortico-medullary borders were less distinct compared to controls. Tiny crystals and mucinous debris lined the papillary tips, calyces and pelvis in 7 of 12 kidneys from treated sows, and multiple stones were noted at the papillary tips in these kidneys. H&E revealed crystals in collecting tubules and papillary tips of 67% of kidneys from HP treated animals and in none of the controls. Yasue staining confirmed crystals in proximal peri-glomerular tubules of treated but not control animals (Fig 1). Tubular dilation, fibrosis and interstitial nephritis was identified with H&E and PAS in kidneys from treated animals (Fig 2); none of these changes were evident in control kidneys, which appeared normal. Conclusions: This is the first report of dietary-induced calcium oxalate stones in adult swine, with crystalluria in proximal peri-glomerular tubules and collecting ducts, and tubular damage at all levels of tubules. Further studies will allow us to elucidate the etiology of renal damage and identify potential preventive mechanisms.

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ABSTRACT #7 10-Year Single Center Experience with Chronic Ureteral Stent Placement for Malignant Obstruction Assessment of Long-Term Durability Jennifer E. Heckman, Jason Carr, Stephen Y. Nakada Madison, WI Objectives: The optimal management of ureteral obstruction caused by extrinsic malignancy remains a challenge. We assessed the efficacy of chronic retrograde ureteral stent placement for malignant ureteral obstruction and examined factors contributing to their success or failure over 10 years. Methods: We performed a retrospective analysis of patients who underwent retrograde ureteral stent placement for malignant ureteral obstruction at a single institution from January 1, 1999 to December 31, 2009. Patient demographics as well as pre- and post-ureteral stent placement variables were abstracted through chart review. The endpoint which determined stent duration in successful cases was death. Stent failure was defined as the need for an alternative procedure to alleviate unresolved symptoms or maintain kidney function. Univariate and multivariate analyses were performed to identify the association of clinical covariates with stent failure. Results: Retrograde ureteral stent placement was performed for malignant ureteral obstruction in a total of 80 ureters in 74 patients. Mean patient age was 61.3 years (range, 35-93). Sixty five percent of patients were female, and the most common malignancies were ovarian cancer (15), lymphoma (10), transitional cell cancer (8), and cervical cancer (8). Stent placement failed in 21of 80 (26.3%) ureters. Mean stent duration was 205 days (range, 2-1350 days) in successful cases and 169 days (range, 1-923 days) in failed cases. Mean overall stent duration was 195 days. Factors found to be predictive of failure were solitary kidney (p = 0.02) and stent malfunction (p < 0.01). Conclusions: Among patients with ureteral obstruction caused by malignancy, solitary kidney and stent malfunction were associated with greater likelihood of stent failure. Mean overall stent duration was 195 days, and 169 days in cases which required alternate drainage. Our series indicates that, on average, chronic stenting for malignant obstruction lasts less than one year.

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ABSTRACT #8 Patient Education and the Impact on Ureteroscopy Experience Nathan D. Grunewald, Alison R. Marciniak, Carley M. Davis, MD Milwaukee, WI Introduction: Ureteroscopy is a common procedure in Urology requiring instrumenting a patient’s ureter with a ureteroscope. To manage procedural related ureteral edema and prevent obstruction a ureteral stent is often placed to allow ureteral inflammation to subside post operatively. While the stent alleviates the concern for edema, it can create stent related discomfort and may increase patient anxiety. Additionally, many stents used during this procedure may be removed by the patient at home at a predetermined time which can also increase post procedure anxiety. Managing these issues post operatively can result in numerous phone calls and/or emergency department/clinic visits. Our goals were to provide patient education materials in the form of a new handout and intensive counseling prior to and after ureteroscopy to improve the patient’s post-operative experience as measured by decreased patient phone calls and/or clinic/emergency department visits. Methods: The study was a retrospective chart review of all patients from a single surgeon who underwent ureteroscopy for stone disease over a six month period. During the review period, implementation of intensive preoperative counseling and dissemination of a newly designed ureteroscopy handout occurred in an attempt to alleviate post-operative patient concerns and emergency department visits for known procedural effects (mild to moderate pain, pain on urination, hematuria, etc.). Results: Based on our experience, a patient’s post ureteroscopy experience can be managed with the intensive counseling and patient education materials. Managing patient expectations is an important component in the comprehensive care of patients with nephrolithiasis who require ureteroscopy and ureteral stent placement. Further sub-group analysis will be completed to identify additional patient factors which lead to increased post ureteroscopy patient concerns and/or emergency department visits.

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ABSTRACT #9 Impact of Male Age on Pregnancy Rates After Bilateral Vasovasotomy Anand Shridharani, Donald Neff, Gabriel Fiscus, and Jay I. Sandlow Milwaukee, WI Introduction: Although female age and obstructive interval are known factors influencing pregnancy rates after vasectomy reversal, the effect of male age has not been examined. Methods: One-hundred and sixty-two patients underwent bilateral vasovasostomy with adequate pregnancy follow-up on 90. All surgeries were performed by a single surgeon (JIS) between 3/2004 and 6/2011, using a microscopic technique. Patients without 1 year follow-up and/or pregnancy data were excluded from the analysis. Results: Pregnancy rates for men <40 vs 40+ years old are 63% and 53%(p=0.3), respectively. The mean partner age was 30.9 and 34.4 in the <40 and 40+ groups, respectively(p<0.001). The obstructive interval between the group <40 and 40+ was 6.0 and 9.3 years (p<0.001). Comparing the couples who got pregnant versus those who did not with regards to obstructive interval, <40 group 5.8 vs 6.7 years out and 40+ group 9.0 vs 10.6 years out, there was no significant difference between the groups with regards to pregnancy rates and obstructed interval. Conclusion: These preliminary findings suggest male age does not impact pregnancy rates following bilateral vasovasostomy.

ABSTRACT #10 Management of Peyronie’s Disease within the NCSAUA as Assessed by E-mail Survey Octavia N. Devon, Daniel H. Williams, IV, David R. Paolone, MD Madison, WI

Objective: Practice patterns for management of Peyronie's disease (PD) by members of the North Central Section of the American Urological Association (NCSAUA) were assessed by email survey with regards to use of oral medication, intralesional injections, traction devices, surgery, and imaging. Methods: An email containing a link to the study survey and the subject heading "Peyronie's Disease Survey" was sent to 1,221 members of the NCSAUA. Responses were assessed 4 days after the survey was sent. Results: Seventy-seven physicians completed the survey (response rate 6.3%). Sixty-three (81.8%) of respondents treat men with PD themselves, while 14 (18.2%) refer these men to another urologist. Forty-five of these 63 urologists (71.4%) treat patients with oral therapy, with Vitamin E being the most commonly used oral treatment. Intralesional injections are performed by 30/63 (47.6%), with verapamil being utilized 96.6% of the time. Thirty-eight of the 63 (60.3%) use vacuum erection devices, penile traction, or both in the management of PD. Surgery is performed by 48/63 (76.1%), and the majority of these urologists offer tunicoplication, grafting procedures, and penile prosthesis implantation. Only 12/63 (19.0%) order any imaging studies for patients with PD. Conclusions: An email survey assessment of practice patterns for management of PD by members of the NCSAUA reveals that the majority treat these men themselves instead of referring to another urologist. Vitamin E remains a frequently-used treatment, and intralesional injections are performed by fewer than half of respondents. Multiple surgical options are offered by a significant proportion of urologists treating PD. The low response rate for the survey raises concern for a lack of enthusiasm or confidence in the treatment of men with PD.

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ABSTRACT #11 90 Urological Management of Fertility Options Following Previous Vasectomy: Analysis of Current Practice Ola Blach, Anand Shridharani, Ira Sharlip, Arnold Belker, Jay Sandlow Milwaukee, WI Introduction: The recently completed AUA Vasectomy Guidelines identified vasectomy reversal (VR) as one potential area for further research. Current practice is characterized by wide variation in preoperative counseling, surgical technique and postoperative follow-up amongst urologists. The objective of this study was to review the management of fertility options following previous vasectomy and compare the performance of urologists with and without andrology fellowship based on ten index parameters deemed to reflect best practice. Methods: In October 2012, a questionnaire-based audit was undertaken of all AUA affiliated urologists regarding their individual practice in managing men requesting VR. Fisher’s exact test was used to test the hypothesis that the management of fertility options following previous vasectomy, and the practice of VR, are no different when undertaken by urologists with and without andrology fellowship training. Results: Of the 645 respondents, 325 (50.4%) performed VR. The majority, 54.1%, performed 1-5 VR a year with just 11.9% performing >25 per year (p<0.0001). 74 urologists were fellowship trained in andrology or male infertility, while 235 performed VR without subspecialty training; responses from the 16 who did not provide this information were excluded from analysis. Differential performance of the urologists with and without andrology training is shown below, along with p-values for the Fisher’s exact test. Conclusions: There are significant differences in the standards of practice of VR by urologists with and without andrology fellowship training. The vast majority of non-fellowship trained urologists perform <5 VR per year. These physicians are significantly less likely to counsel couples about all fertility options, be conversant in IVF/ICSI, provide individualized outcomes data, as well as utilize microsurgical techniques. Based on these differences, outcomes data should be analysed to determine if success rates differ, and if so, guidelines should be established.

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INDEX PARAMETER

US UROLOGISTS (309)

p-value

ANDROLOGY TRAINED

74 (23.9%)

NON-ANDROLOGY

TRAINED 235

(76.1%) Perform >25 vasectomy reversals per year

29 (39.2)

8 (0.03) 0.0001

Insist on or prefer seeing both partners

63 (85.1)

161 (68.5) 0.0046

Discuss all options for parenting in detail

60 (81.1)

120 (51.1) 0.0001

Fully conversant with criteria for IVF/ICSI

72 (97.3)

122 (51.2) 0.0001

Individualised information about expected outcome

74 (100)

234 (99.6) 1.0000

Quote own outcomes 44 (59.5)

68 (28.9) 0.0001

Quote figures from literature

30 (40.5)

166 (70.6) 0.0001

Use an operating microscope

74 (100)

184 (78.3) 0.0001

Use loupes intra-operatively - 50

(21.3) 0.0001

Routinely evaluate intraoperative vas fluid for microscopic exam

70 (94.6)

160 (68.1) 0.0001

If no sperms seen, perform vasoepididymostomy

71 (95.9)

89 (37.9) 0.0001

Retrieve sperm at the time of vasovasostomy, routinely or if asked

67 (90.5)

80 (34.0) 0.0001

Perform microscopic 2 layer closure

53 (71.6)

106 (45.1) 0.0001

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ABSTRACT #12BCG-Induced Depletion of Intracellular ATP in Human Urothelial Carcinoma Cell Lines Bryan Sack, Gopitkumar Shah, Gang Cheng, Jacek Zielonka, Balaraman Kalyanaraman, William SeeMilwaukee, WI

Objectives: Decreases in intracellular energy levels (ATP) are known to correlate with the extent of cellular injury and the mechanism of cell death (apoptosis vs. necrosis). Earlier reports have shown that exposure of urothelial carcinoma (UC) cells to Bacille Calmette Guerin (BCG) results in necrotic cell death and release of the potent necrosis associated chemokine HMGB1. This study focuses on the effect of BCG on intracellular energy.Methods: Two human UC cell lines (253J and T24) were used to study cellular ATP levels in tumor cells subsequent to BCG exposure. The direct relationship between intracellular ATP levels and the conversion of luciferin to light by luciferase was used to measure ATP levels as a function of time following BCG exposure. Results: Treatment of UC cell lines with BCG resulted in significant decrease in cellular ATP levels in a time-dependent manner. Cellular ATP levels showed a 45% decrease in both cell lines after 144 h. Table 1 provides the average percent change for ATP as a function of time following BCG treatment.Conclusions: Exposure of UC cells to BCG results in a time-dependent decrease in intracellular ATP. ATP depletion represents a potential target for strategies designed to improve BCG treatment efficacy.

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ABSTRACT #13 Leukemoid Reaction: A Rare Paraneoplastic Syndrome in Urothelial Cancers Associated with a Grave Prognosis Daniel D. Shapiro, Kelvin Wong, E. Jason Abel, Tracy M. Downs Madison, WI Presentation to be made by Daniel Shapiro Introduction: Leukemoid reaction is a rare paraneoplastic process that occurs in multiple different tissue malignancies, but is rarely encountered in association with urothelial carcinoma. Leukemoid reaction is defined as a tumor induced leukocytosis that resembles leukemia in the absence of infection. Recent studies have demonstrated the role of Granulocyte-colony stimulating factor in causing leukocytosis associated with urothelial carcinoma. Early detection of leukemoid reaction is essential as it is commonly associated with more aggressive tumors of the urothelial tract. The objective of our study is to report the challenges in diagnosing this rare paraneoplastic process and its impact on patient prognosis. Methods: We selected patients with a preoperative white blood cell count (WBC) > 20 x 103/μl from a group of 405 patients who underwent radical cystectomy with curative intent from 2002-2012. Clinical and pathologic variables were analyzed as well as postoperative WBC and disease specific survival to determine those who had leukemoid reaction. Criteria for leukemoid reaction included preoperative WBC > 50 x 103/μl, normalization of WBC postoperatively, and no other known etiology of elevated WBC such as infection or leukemia. Results: Five patients had a preoperative WBC > 20 x 103/μl. Mean age was 60.8 years. Mean WBC was 36.9 x 103/μl. Only a single patient fit the criteria for leukemoid reaction. We present a case of a 43-year-old man with a history of urothelial carcinoma with an associated leukemoid reaction. Pre-operative workup demonstrated no evidence of metastatic disease but did reveal an elevated white blood cell count, which continued to rise over the pre-operative course. A radical cystectomy dramatically improved his elevated white blood cell count to within normal range. One month after cystectomy, he developed a recurrence of leukocytosis and was found to have metastatic urothelial carcinoma. Shortly after he succumbed to his cancer. Conclusions: Diagnosing leukemoid reaction early provides a unique and complicated challenge. Many other clinically similar appearing entities must first be ruled out such as infection and leukemia. This case demonstrates the aggressive nature of urothelial malignancies associated with this paraneoplastic syndrome.

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ABSTRACT #14 BCG Induces Oxidative Stress as Demonstrated by Lipid Peroxidation in Human Urothelial Carcinoma Cell Lines Gina M. Lockwood, Fanghong Chen, William A. See Milwaukee WI Introduction: Cellular oxidative stress (COS) following cell internalization of Bacillus Calmette Guérin (BCG) has been shown to be a critical mechanism underlying the direct effects of BCG on urothelial carcinoma (UC) cells. Treatment-induced free radicals can cause damage to cellular molecules contributing to cell death. Lipid peroxidation is the oxidative degradation of membrane lipids, and is a cellular consequence of free radical injury. This study aims to quantify COS-induced damage to lipids occurring as consequence of BCG treatment Methods: Lipid peroxidation was quantified in human UC cell lines 253J and T24 following treatment with BCG. ELISA assay for an established marker of lipid peroxidation (4-hydroxy-nonenol (HNE)) was performed after 72 hours of exposure to BCG. The impact of hydrogen peroxide (H2O2) generation on COS-induced lipid damage was determined by comparing the effects of viable BCG (normal H202 production) vs. heat-killed BCG (impaired H2O2 production). The contribution of the inducible nitric oxide synthase (iNOS)/NO pathway to oxidative damage was determined by pretreatment of cells with iNOS inhibitor 1400W. Results: Compared to untreated controls, concentrations of the lipid peroxidation by-product 4-HNE were significantly increased in both cell lines following treatment with BCG or hkBCG. Treatment with BCG resulted in higher levels of HNE compared to hkBCG. Addition of iNOS inhibitor 1400W demonstrated a significant decrease in BCG treatment effect. See table. Conclusions: Treatment of UC cells with viable BCG results in oxidative cellular damage as evidenced by increased levels of lipid peroxidation end-products. Decreases in BCG-generated H2O2 in hkBCG are associated with lower levels of oxidative damage. Inhibition of iNOS/NO markedly decreases lipid damage in response to BCG. These results suggest that COS in response to BCG is mediated through multiple pathways and impacts critical cellular components. Table 1: 4-HNE levels following BCG and hkBCG treatment

HNE (pg/ml)

Control cell lines (T24+253J)

47.8

BCG treatment 225.0 (p<0.001)

hkBCG treatment 136.5 (p<0.001)

Change in effect with BCG + 1400W

-128.5 (p<0.001)

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ABSTRACT #15 Preoperative Neutrophil Lymphocyte Ratio (NLR) Correlates with Tumor Stage and Tumor Grade Found at the Time of Transurethral Resection of Bladder Tumors Daniel D. Shapiro, Aaron Potretzke, Muta M. Issa, Luke Hillman, Ryan W. Dobbs, Viraj Master, E. Jason Abel, Daniel Canter, Tracy M. Downs Madison, WI Introduction: Neutrophil−lymphocyte ratio (NLR) is an indicator of systemic inflammation and has been shown to be prognostic for outcomes in other cancers but evidence is lacking in bladder cancer. The purpose of our study was to evaluate the utility of NLR to distinguish between different tumor stages and grades for patients with transitional cell carcinoma (tcca) of the bladder. Methods: The records of consecutive patients who underwent TURBT for tcca of the bladder were reviewed from two institutions (2002-2012 U Wisconsin, 2000-2012 Emory University). NLR was calculated from patients who had a complete blood count with differential performed prior to TURBT. NLR ratio was compared across T-stage, tumor grade and ethinicity (African-American –AA and Caucasian-American – CA). Wilcoxon rank sum test and Kruskal-Wallis test were used for statistical analysis. Results: 297 consecutive patients (Emory-168, UW-129) patients met our study criteria. Mean age 66.7 years, males 89%, females 11%, Caucasian 86%, African-American 14%, mean BMI 28.5 kg/m2 and mean white blood cell count (wbc) 8.1. Clinical stages after TURBT were, Ta (41%), T1 (22%) and T2 (37%). For Ta patients (66% low-grade, 34% high-grade), T1 patients (100% high-grade) and T2 patients (3% low-grade, 97% high-grade). Mean NLR ratios were statistically different across T-Stages (Ta-2.4, T1-3.3, T2-4.0; p <0.001), tumor grades (low-2.4, high-3.5, p=0.006), and ethinicity (AA -1.9, CA - 3.4, p <0.001). NLR remained statistically different across T-stages when only high-grade tumors were analyzed (p=0.005). Conclusions: Higher NLR are associated with higher tumor stages and tumor grades. African-American patients have lower NLR scores across all tumor stages and grades compared with Caucasian-Americans. More studies are required to confirm the utility of NLR in patients diagnosed with bladder cancer.

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ABSTRACT #16 BCG Treatment of Human Urothelial Carcinoma Cells Induces Oxidative DNA Damage Scott C. Johnson, Fanghong Chen, William A. See Milwaukee, WI Introduction: Abundant data highlights cellular oxidative stress (COS) following cellular internalization of Bacillus Calmette Guérin (BCG) as an important mechanism underlying the direct effects of BCG on urothelial carcinoma (UC) cells. Treatment-induced free radicals can cause damage to cellular molecules and organelles contributing to loss of viability and cell death. Oxidative DNA damage and resulting activation of DNA repair molecules can ultimately result in cell necrosis. The purpose of this study is to quantify COS-induced damage to DNA occurring as consequence of BCG treatment. Methods: Intracellular DNA damage was quantified in two human UC cell lines (253J and T24) following treatment with BCG. An ELISA assay for the marker 8-hydroxydeoxyguanosine (8-OHdG), a byproduct of oxidative DNA damage was performed. 8-OHdG levels were measured after 24 hours of exposure to BCG. The impact of BCG H2O2 generation on COS-induced DNA damage was determined by comparing the effects of viable vs heat killed BCG (impaired H2O2 production). The contribution of the iNOS/NO pathway to oxidative damage was determined by pretreatment of cells with the iNOS inhibitor 1400W. Results: Compared to controls, concentrations of the DNA oxidative damage marker 8-OHdG were significantly increased in both cell lines following treatment with BCG or hkBCG. Control cell lines had an average 8-OHdG level of 4.88 pg/ug DNA, while those treated with BCG and hkBCG had levels of 9.24 pg/ug DNA and 10.36 pg/ug DNA, respectively. The difference between BCG and hkBCG cell lines was not statistically significant. Addition of the iNOS inhibitor 1400W demonstrated a decrease in 8-OHdG levels by an average of 3.78 pg/ug DNA, which was also statistically significant. Conclusions: Treatment of cells with viable BCG results in oxidative cellular damage as evidenced by increased levels of DNA oxidation end-products. Decreases in BCG generated H2O2 in hkBCG are associated with lower levels of oxidative damage. Inhibition of iNOS/NO markedly decreases DNA damage in response to BCG. These results suggest that COS in response to BCG is mediated through multiple pathways and impacts critical cellular components.

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ABSTRACT #17 Ketamine Based Multimodal Analgesia Decreases Time to Bowel Movement and Discharge After Robotic-Assisted Cystectomy and Urinary Diversion Tanya D. Davis, MD, Robert J. Schlosser, MD, Kenneth M. Jacobsohn, MD, Peter Langenstroer, MD, William A. See, MD, John Tlachac, MD, Karin Madsen, MD Milwaukee, Wisconsin Introduction: Post-operative ileus is common in patients undergoing radical cystectomy with urinary diversion. To limit side effects of opioid analgesia on bowel function, we instituted a novel ketamine based multimodal analgesic regimen in the peri-operative period. Primary end points were time to return of bowel function, time to discharge and the safety and efficacy of the analgesic regimen.. Methods: A retrospective chart review of patients undergoing robotic-assisted cystectomy with urinary diversion by a single surgeon from 1/1/2011 to 6/30/2012 was performed. Exclusion criteria included patients with chronic pain or those deemed medically unable to receive the either ketamine analgesia or transversus abdominis plane (TAP) block. Patients on the opioid minimizing protocol (Group A) were compared to a cohort undergoing an identical surgical procedure but receiving opioid predominant analgesia (Group B). Results: Group A included 18 patients, and there were 25 in Group B. Average age was 67 and 65 in Group A and B respectively (P=0.5). Both groups were male predominant (75%) with average ASA classification of 3. 75% of Group A and 50% of Group B received neoadjuvant chemotherapy (P=0.5). 3 patients (16.6%) in Group A had to discontinue the protocol secondary to ketamine intolerance. No patients had long term side effects. Of the 15 that did complete the protocol, 10 (63%) utilized breakthrough opioid analgesia. Mean time to bowel movement and hospital discharge was 3, and 4.5 days versus 6 and 8 days in Group A versus Group B (P=0.002). Conclusions: Multi-modal ketamine based analgesia was found to be safe and effective in the cystectomy and urinary diversion population. Patients who completed the protocol had a shorter time to return of bowel function and discharge to home than patients receiving opioid predominant analgesia. A larger, prosepective trial is needed to confirm these results.

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ABSTRACT #18 Enhancing the Therapeutic Benefit of Deflux for Vesico-Ureteral Reflux with Adjunctive Therapies Morgan K. Prince, Anthony H. Balcom Milwaukee, WI Objectives: Vesico-ureteral reflux in children contributes to urinary tract infection and renal disease, and is frequently treated with sub-ureteric injection of a bulking agent, Deflux®. We postulated that: 1. treating urethral stenosis, when present, would minimize dysfunctional voiding post-procedure, increasing the efficacy of Deflux®, and 2. use of oral post-operative phenazopyridine hydrochloride, a urinary tract analgesic, would decrease post-operative dysuria, thus minimizing retention of urine, allowing better encapsulation rather than deformation of the Deflux® bleb, enhancing the success rate of Deflux®. In this study, we assessed: 1. the effects of urethral dilatation for urethral stenosis, and, 2. post-operative use of oral phenazopyridine hydrochloride on the success rate of Deflux® treatment for vesico-ureteral reflux. Methods: We studied 146 girls treated for vesico-ureteral reflux with Deflux® in a retrospective cohort study. After excluding 56 girls with secondary reflux, 90 girls with primary vesico-ureteral reflux were treated with endoscopic injection of Deflux® over a 3 year period at Children’s Hospital of Wisconsin by three pediatric urology attending surgeons. One of these three routinely calibrated the urethra, defining stenosis as 14 Fr. Or less, and performing urethral dilatation when stenotic. A successful outcome after Deflux® injection was defined as a post-operative absence of vesico-ureteral reflux by voiding cystourethrogram. Results: An overall success rate of 59% (127/146) was observed in girls treated with Deflux®. The girls with primary vesico-ureteral reflux showed an overall success rate of 61% (90/127) from Deflux®. Of these 90, 27 girls underwent urethral dilatation at the time of Deflux® injection, and 14 received post-operative phenazopyridine hydrochloride. The girls who underwent urethral dilatation had an 82% (27/90) success rate compared to 52% (63/90) for those who did not; p < 0.05. The girls who received post-operative phenazopyridine hydrochloride demonstrated a success rate of 86% (14/90) compared to 57% (76/90) in girls who did not; p < 0.05. Conclusions: This study indicates that when Deflux® is used for treatment of primary vesico-ureteral reflux in girls, urethral dilatation had a positive effect on success rate. Oral post-operative use of phenazopyridine hydrochloride in conjunction with endoscopic injection of Deflux® for treatment of primary vesico-ureteral reflux demonstrated a similar positive effect on success rate. We conclude that these adjunctive measures can clinically decrease intra-vesical pressure post-operatively, theoretically allowing encapsulation rather than deformation of the Deflux® bleb. Persistence of the Deflux® bleb seems to be associated with enhanced success rates of cure for vesico-ureteral reflux, so consideration of incorporating urethral dilatation and oral phenazopyridine hydrochloride into the algorithm for treatment is warranted.

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ABSTRACT #19 Management of Feminizing Testis Tumors in Prepubertal Boys Justin O. Benabdallah, Patricia Donohoue, Anthony H. Balcom, MD Milwaukee, WI Introduction: Feminizing pre-pubertal testis tumors are a rare and have a well- established pathology in the literature. Herein, we review the presentation, evaluation, differential diagnosis, and management of feminizing testis tumors in prepubertal boys. Methods: A recent seven-year-old boy with gynecomastia and an intra-abdominal testis will serve as the springboard for discussing the literature, endocrinology, preoperative evaluation, and intra-operative management of feminizing testis tumors. Our emphasis is on management, specifically reviewing intra-operative decision-making in regards to the role of testis-sparing surgery. The post-operative role of genetic evaluation and counseling will also be reviewed. Conclusions: Feminization, particularly gynecomastia, is a very rare presenting sign of a testicular tumor in prepubertal boys. These tumors require unique, specialized management, with a very limited role for testis-sparing surgery despite their low malignant potential. ABSTRACT #20 A Retrospective Study of Urolithiasis, Obesity, and other Potential Predictors in a Midwestern, Pediatric Population John T. Roddy, Anas I. Ghousheh, Melissa A. Christensen, Laura D. Cassidy, John V. Kryger, MD, Charles T. Durkee Milwaukee, WI Background: Unlike in adults, obesity has not been shown to be a risk factor for kidney stones in children, although it is associated with certain urinary risk factors for pediatric stone disease. To our knowledge the possible relationship between obesity and pediatric urolithiasis has not been sought in the Midwest, which is in a region of high incidence for this disease in children. Hypothesis: (1) There is no association between obesity and pediatric urolithiasis. (2) High body mass index percentile (BMI%) is associated with an altered, non-lithogenic urinary risk factor profile for the disease. Methods: We performed an Institutional Review Board-approved chart review of all upper tract urolithiasis patients without co-morbidities presenting to Children’s Hospital of WI (CHW) from 2006 to 2011, recording BMI% for comparison with state and national obesity data. BMI% was recorded within ± three months of the presentation date, with any BMI% at or exceeding 95% defining obesity. 24-hour urine collection data were recorded in order to compare urinary risk factors between stone patients with high BMI% (BMI% ≥ 85%) and with normal BMI% (5% < BMI% < 85%). Results: 118 stone patients with available BMI% were analyzed by age group. The obesity rates for ages 2-9 years, ages 10-13 years, and ages 14-18 years were 20.0% (n=30), 14.7% (n=34), and 10.5% (n=54), respectively, which are not significantly greater than national and available state obesity rates. No 24-hour urine concentration differed significantly between high and normal BMI% groups across all three age groups, though some differed within age groups. The means and standard deviations of some of the significant urinary risk factors associated with high versus normal BMI% were 6.189±0.376, 6.705±0.524 for 24-hour urine pH (p=0.009) in subjects aged 2-9 (n=26)

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and 399.4±166.9, 686.5±133.2 for 24-hour citrate/creatinine (p<0.0001) in subjects aged 10-13 (n=26). Conclusions: The obesity rate in our sample population versus in available state and national surveys seems to indicate that obesity and pediatric urolithiasis are not associated. Despite a finding of significant differences in risk factors associated with high BMI% within the younger age groups, no difference displays of significance across all three age groups. ABSTRACT #21 Is There a Need for Preoperative Ureteral Stenting in Pediatric Patients Undergoing Ureteroscopy? Dane P. Johnson, Ruth Swedler, Charles Durkee, Travis Groth Milwaukee, WI Objectives: To evaluate the use of passive dilation by stenting of ureteral orifices in children undergoing ureteroscopy for laser lithotripsy of upper tract calculi. Specifically, we sought to determine whether age can predict the likelihood of successful ureteroscopy without stenting, and if any age groups are increased likelihood of needing passive dilation with ureteral stents. Methods: We retrospectively reviewed all patients who underwent ureteroscopic procedures for upper tract calculi from 2000 to 2012 at Children’s Hospital of Wisconsin. Results: A total of 45 patients with upper tract calculi who underwent ureteroscopy were included in this present study. Successful primary upper tract access was achieved in 29 patients without need for previous stenting. Passive ureteral dilation with stents were required in patients. Overall success rate of achieving tract access after passive dilatation with ureteral stents was 100%. The mean age for patients who required passive dilation was 8.4 years, while patients with successful primary upper tract access had mean age of 12.8 years. Conclusion: Passive dilation of ureteral orifice in preparation for ureteroscopy is successful and beneficial in children. Independent patient variable (age) can be used to predict the likelihood of need for ureteral stent placement for passive dilation in children undergoing ureteroscopy. Patients requiring passive ureteral dilation were younger than those with successful primary upper tract access. Analysis of subgroups (<1 years old, 1-5 years old, >5 years old) for likelihood for need of ureteral dilation will be presented at the annual Wisconsin Urological Society meeting in spring of 2013. To our knowledge, there are no prior published studies that compare specific age groups and likelihood of need for passive ureteral dilation prior to successful ureteroscopy.

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ABSTRACT #22 Laparoscopic Cryoablation for Clinical Stage T1 Renal Masses: Long-Term Oncological and Functional Outcomes at The Medical College of Wisconsin Khanh Pham, Frank Begun, Kenneth Jacobsohn, William A. See, Peter Langenstroer, MD Introduction: We report the long-term oncological and functional outcomes of laparoscopic cryoablation for clinical stage T1 renal masses at our institution. Methods: A retrospective chart review was performed evaluating 120 patients who underwent laparoscopic cryoablation at the Medical College of Wisconsin between February 2000 and December 2007. Results: A total of 143 renal masses were treated with laparoscopic cryoablation. Mean patient age was 61.4 years (SD, 13.7; 30-92). Mean tumor size was 2.2 cm (SD, 0.79; 0.86-5). Mean operative time was 181 minutes (SD, 76.0; 78-515). Mean length of stay was 3.3 days (SD, 2.44; 1-16). Mean estimated blood loss was 90.8 ml (SD, 211.1; 5-1700). Mean follow-up was 43.5 months (SD, 25.5; 13-112). Progression-free survival (PFS) was 93%; cancer-specific survival (CSS) was 99%; and overall survival (OS) was 93%. Mean preoperative serum creatinine was 1.07 (SD, 0.78; 0.5-6.6) compared to 1.29 (SD, 0.99; 0.5-8.43) postoperatively at last follow-up (p=0.11). The perioperative complication rate was 8.3%. Conclusions: Laparoscopic cryoablation is a viable treatment option for clinical stage T1 renal masses with excellent long-term oncological and functional outcomes that are comparable to alterative nephron-sparing modalities, such as laparoscopic or open partial nephrectomy. ABSTRACT #23 Comparative Analysis of Tissue Biomarkers and Prognostic Systems to Predict Post Surgical Recurrence in Renal Cell Carcinoma Patients Tyler Bauman, Kelvin Wong, FangFang Shi, David Jarrard, Tracy Downs, Wei Huang, E. Jason Abel Madison, WI Introduction: Surgery is the gold standard for treatment of localized renal cell carcinoma (RCC). After treatment, approximately 1 in 5 patients will progress to metastatic disease. Current prognostic models account for clinical and pathological factors but have limited accuracy. Biomarkers have the potential to increase prognostic accuracy but are an understudied area in RCC recurrence. The objective of this study was to compare the predictive accuracy of several common biomarkers to current prognostic models for RCC recurrence. Methods: An institutional database identified a cohort of RCC patients with N0M0Tany RCC. Clinical and pathologic data were collected and a tissue microarray was constructed from pathologic samples. Intra-tumor expression of Ki-67, CRP, NFκB, HIF1α, HIF2α, and CAIX was evaluated using a high-throughput method for quantitative immunohistochemical staining (VectraTM). Univariate and multivariate Cox proportional hazards analysis was used to compare the prognostic ability of putative biomarkers with clinical and pathologic variables. Probability of 5-year recurrence-free survival was calculated using the Kattan (MSKCC) nomogram and UCLA integrated staging system (UISS). To evaluate whether biomarkers would identify high risk patients which were not included in the risk stratification systems, a cohort of patients with >50% recurrence-free probability was identified from the prognostic systems. Logistic

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regression was used to produce receiver operating characteristic (ROC) curves and areas under the curve (AUC) were calculated. Ki-67 was included as an independent variable in the model and new AUCs were calculated. Results: Analysis included 216 patients with a median age of 61 and a median follow-up of 60.5 months. Specimens were classified as Fuhrman grades 1,2,3,and 4 for 65, 112, 27, and 12 patients respectively. RCC subtypes analyzed include clear cell (156 patients), papillary (38), chromophobe (16), collecting duct (1), and unclassified (5). Of 216 patients, 34 (15.7%) were diagnosed with recurrence. Univariate analysis identified tumor size, grade, stage, subtype, sarcomatoid features, venous thrombus, perinephric fat invasion, and increased Ki-67 expression as risk factors. On multivariate analysis, only tumor size and Ki-67 overexpression were independent risk factors for RCC recurrence, with Ki-67 being most predictive [HR = 2.38, CI = 1.07-5.28]. According to the Kattan nomogram, 197 of the 216 patients had a >50% chance of being recurrence-free at 5 years. Of these, 25 (12.7%) patients recurred. The AUCs for the Kattan nomogram and UISS nomogram for patients >50% recurrence-free probabilities were 0.701 and 0.692, respectively. After addition of Ki-67 to the model, the AUC decreased to 0.660 for the Kattan nomogram and increased to 0.707 for the UISS nomogram. Conclusions: Using an objective quantifiable high throughput method to evaluate tissue protein expression allows identification and validation of RCC biomarkers. Future studies may allow identification of biomarkers to identify high risk patients after surgery or to enable better treatment decision making. Although Ki-67 is independently predictive of RCC recurrence, it failed to significantly increase the accuracy of current prognostic models for patients with a >50% 5-year recurrence-free probability in the current study. ABSTRACT #24 Safety and Feasibility of Percutaneous Microwave Ablation for Renal Parenchmal Tumors Kelvin S. Wong, Sara L. Best, Anna J. Moreland, Timothy J. Ziemlewicz, J. Louis Hinshaw, Fred T. Lee, Jr., Christopher L. Brace, Meghan G. Lubner, Marci L. Alexander, Stephen Y. Nakada, E. Jason Abel Madison, WI Objective: To evaluate the feasibility and safety of a high powered, gas-cooled microwave ablation system (NeuWave Medical, Madison WI) for the treatment of renal parenchymal tumors. Methods: We reviewed patients who underwent percutaneous microwave ablation for renal parenchymal tumors. Clinical and pathologic data were collected and technical success was assessed by lack of residual enhancement on post ablation CT. Complications were evaluated using the Society of Interventional Radiology (SIR) classification system. Results: Between January 2011 and October 2012, 23 patients at a single institution underwent CT or ultrasound guided percutaneous microwave ablation with a median follow up of 8 months. Biopsy pathology of renal masses included: renal cell carcinoma (n=17), angiomyolipoma (n=4), and oncocytoma (n=2). The mean maximum tumor diameter was 3.1 cm (range 1.5-5.4 cm). Technical success was achieved in all tumor ablations. Postoperative urinary retention was the only perioperative complication reported. Length of hospital stay was <24hours in all patients. Conclusion: Percutaneous microwave ablation is a technically feasible and safe method for treating select renal parenchymal tumors. Further studies are needed to evaluate long-term oncologic outcomes compared to other ablation modalities and surgery.

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ABSTRACT #25Multiphoton Microscopic Characterization of Renal Cell CarcinomaSara L. Best, E. Jason Abel, and Kevin W. EliceiriMadison, WI

Introduction: Optical biomarkers assessed via multiphoton microscopy (MPM) and Second Harmonic Generation Microscopy (SHG) have been linked to prognosis and outcomes in ovarian and breast cancer. These optical approaches can assay both H&E stained and non-stained samples to look at both labeled elements and intrinsic signals such as autofluorescence and SHG from collagen. We sought to characterize renal cell carcinoma (RCC) with MPM to assess for any changes in these intrinsic signals that correlated with pathologic assessment.Methods: An unstained tissue microarray was constructed using 0.6mm cores of renal tissue specimens. Samples from 88 patients were analyzed with MPM, including 61 from RCCs grades 1-4 and 17 that were benign. A multiphoton workstation equipped with a Ti:Sapphire laser set to an excitation wavelength of 890nm was used to analyze each specimen. This technique generated both second harmonic generation (SHG) and autofluorescence images that are separable by optical filters. The images were then compared.Results: Unstained renal tissue, both benign and malignant, generates excellent intrinsic signals, both SHG and autofluorescent, that were detected with MPM. Initial efforts to characterize differences among Fuhrman grades of RCC identified detectable differences in collagen patterning (Figure 1). These differences are also apparent on the small samples used in the microarray, which are similar to those that might be obtained from a renal tumor biopsy.Conclusions: Multiphoton microscopy provides a flexible platform with which to analyze renal tumors and may provide additional information to characterize both whole specimens and biopsy cores. Further studies will aim to quantify renal cancer optical biomarkers and associate them with patient outcomes.

Figure 1: Multiphoton images of two grades of clear cell RCC (grade 1 and 4). Images were obtained using a 20x lens with 3.9x zoom.

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ABSTRACT #26 Development of Multi-Institutional Validation of an Upgrading Risk Tool for Biopsy Gleason 6 Prostate Cancer Matthew Truong, Jon A. Slezak, Chee Paul Lin, Viacheslav Imremashvili, Martins Sado, Aria A. Razmaria, Glen Leverson, Mark Soloway, Scott Eggener, Edwin J. Abel, Tracy M. Downs, and David F. Jarrard Introduction and Objectives: Men with low risk prostate cancer (PCa) frequently undergo Gleason score upgrading after radical prostatectomy (RP). There are currently no validated nomograms employing variables available before surgery for predicting upgrading in lower risk PCa patients. Thus, we developed a nomogram for predicting upgrading in Gleason 6 patients that is validated in modern, external populations. Methods: Nomogram development was performed using 413 consecutive Gleason 6 biopsy patients who underwent RP using clinical and pathological data. External validation was performed in two separate cohorts consisting of 1151 patients and 392 patients. Clinical variables included age, BMI, PSA, AUA symptom score, race, family history of PCa, smoking history, ASA physical status, surgical approach, clinical stage, and DRE estimation of prostate size. TRUS-guided biopsy was performed in all patients with the following variables collected: TRUS-estimated prostate size, estimated tumor volume, maximum core involvement, no. of positive cores, total no. of cores, and laterality. Results: On multivariate analysis, significant predictors of Gleason 6 upgrading were PSA density (OR=1.72 per 0.1 unit increase, p=0.003), obesity (OR=1.90 with BMI≥30, p=0.047), number of positive cores (OR=1.23 per 1 unit increase, p=0.013), and maximum % core involvement (OR=1.02 per 1% unit increase, p=0.009). On internal validation, the bootstrap-corrected predictive accuracy was 0.721 (p<0.0001). External validation revealed predictive accuracies of 0.677 and 0.672, respectively (all p<0.0001). The nomogram was well calibrated in all cohorts and decision curves demonstrated high positive net benefit across a wide range of threshold probabilities. Conclusion: We have developed and externally validated a nomogram that uses clinical parameters and biopsy findings to predict the risk of pathological upgrading in patients with Gleason 6 prostate cancer on biopsy. This nomogram may be used in counseling patients regarding their management options.

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ABSTRACT #27 Novel Nomogram for Risk Stratification in Patients Considering Active Surveillance for Low-Risk Prostate Cancer Jonathan M. Shiau, Matthew Truong, Jon Slezak, David F. Jarrard Madison, WI Objective: Active Surveillance (AS) is a treatment option for low-risk prostate cancer (PCa). Increasing Gleason grade and tumor volume on repeat prostate biopsy are used as criteria for initiating more aggressive treatment in patients on AS. An externally validated nomogram was previously developed to predict upgrading of Gleason 6 PCa at radical prostatectomy (RP) using variables available at the time of diagnosis. We applied this nomogram to our AS population, to evaluate its potential role in predicting AS failure. Methods: Clinicopathologic data was examined for Gleason 6 patients who met AS criteria (PSA ≤ 10, Gleason ≤ 6, Max Core involvement ≤ 50, and ≤2 cores involved), yet underwent RP at three separate academic centers (N=131, N=686, and N=193, respectively). In this cohort, BMI, PSA density, number of positive cores and maximum core involvement were identified as independent predictors of Gleason upgrading on final pathology, and these variables were used to create a nomogram to predict Gleason upgrading. We then reviewed our institutional AS cohort (mean follow up 32 months), and applied our nomogram to generate a risk score. The ability of the risk score to predict AS failure was assessed using univariate and multivariate Cox proportional-hazards analyses. Two different AS failure endpoints were evaluated using separate Cox models: 1) maximum core involvement >50% (MCI) and 2) Gleason score >6 on subsequent biopsy. Results: Applying the nomogram to patients that met AS criteria, but underwent RP, at three separate institutions demonstrated AUCs of 0.708, 0.630, and 0.714, respectively (all p<0.05) for predicting Gleason upgrading. This established its validity in low risk patients. We then examined a cohort of 102 AS patients at our institution of which 67 had the necessary clinical data to apply to our nomogram. On univariate analysis, the risk score predicted failures in MCI and Gleason upstaging (p=0.03 and 0.01, respectively). On multivariate analysis the risk score was an independent predictor of MCI and Gleason failure (p = 0.03 and 0.01, respectively). We found that 7.46% (5) and 20.90% (14) of the AS cohort failed using these 2 criteria, respectively. Conclusions: This novel nomogram for low risk patients generates a risk score that is an independent predictor of Gleason and max core involvement failure. This information is available for AS patients at the time of diagnosis and provides a continuous risk assessment for failure that can play a role in counseling patients considering AS.

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ABSTRACT #28 Robotic Simple Prostatectomy Alex Zacharias, Mark Dykstra, Sameer K. Sharma, Michael J. Krco Grafton, WI Introduction: Minimally invasive approach using robotic assisted simple prostatectomy are replacing the gold standard open surgical approach, potentially reproducing its results with lower morbidity. We report the feasibility of robotic assisted simple prostatectomy. Methods: The series consists of 7 cases of robotic assisted simple prostatectomy performed between July 2011 and March 2012. All patients had symptomatic BPH with a mean prostate volume of 167gm with 3 patients in urinary retention. One patient had recurrent BPH related hematuria despite having undergone 2 laser TURP’s. All patients had elevated PSA and were ruled out for malignancy by transrectal sonography and biopsy. Results: Average age for the patient group was 65.3 years (range 46 to 80) and a mean PSA of 9.1. The estimated blood loss averaged 257ml(range 100 to 400 ) and a mean operative time was 218 min(range180 to 300). Average foley catheter duration was 11.5 days. Mean specimen weight on pathological examination was 100gram (range58 to 144gm). Mean hospital stay was 1.4 days and no patient required blood transfusion. Considerable improvement from baseline was noted in international prostate symptoms score (preoperative vs postoperative 19 vs 3) and maximum urine flow (preoperative vs postoperative 3 vs 21 ml per minute). There were no acute intra-operative or peri-operative complications. No post- operative incontinence or bladder neck contractures were encountered. Conclusions: Robotic assisted retropubic simple prostatectomy is feasible and a reasonable and safe alternative to open technique. Faster recovery and reduced blood loss are potential benefits to this approach.

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ABSTRACT #29 Epsilon Aminocaprioic Acid for the Treatment of Refractory Upper Tract Hematuria in a Patient with Medullary Sponge Kidney Dustin A. Pagoria, Peter Langenstroer Milwaukee, WI Objectives: Refractory upper tract hematuria may occur secondary to non-traumatic etiologies such as hematological disorders or intrinsic kidney disease (e.g., medullary sponge kidney). In this report we summarize our experience with the use of epsilon aminocaproic acid in a 53 year old female with refractory upper tract hematuria secondary to medullary sponge kidney with nephrocalcinosis. She described episodes of gross hematuria over the past eight years and worsening bleeding episodes necessitating blood transfusion over a three-month period. Two attempts at ureteroscopic management failed and therefore an alternative therapy was needed. Methods: We report on our results with the use of epsilon aminocaproic acid as a method of treating refractory lateralizing upper tract hematuria after more conservative measures failed in a patient with medullary sponge kidney. Results: A Pubmed literature search was performed to analyze the efficacy of this therapy as well as the current risks and benefits associated with this therapy. Conclusion: Epsilon aminocaproic acid is potentially useful in the management of refractory upper tract hematuria in patients when renal preservation is desired. Due to potential side effects, epsilon aminocaproic acid should be used with caution.

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*ABSTRACT #30 Pure Adult Yolk Sac Tumor of the Testis Presenting with Scrotal Violation: An Interesting Case Amul M. Shah, Jay I. Sandlow, Gary Sudakoff, Anand N. Shridharani, MD Introduction: Yolk sac tumor of the testis, although common in the pediatric population, is less frequently seen in the adult population, especially in its pure form, with a very limited number of cases being reported in the literature. Herein, we present a case of an adult patient presenting with scrotal bleeding and swelling, and ultimately found to have a pure yolk sac testicular tumor. Case Presentation: A 25-year-old otherwise healthy male presented to the emergency room with 3 days of progressive right hemi-scrotal swelling that resulted in spontaneous bleeding from his scrotum. On physical exam, he was found to have a firm right hemiscrotum with a non-palpable right testis and with a 1 cm circular area of ulceration on the inferior portion of the right scrotum. Scrotal ultrasound demonstrated findings suggestive of rupture of the right testicle with surrounding hematoma. Tumor markers were elevated at presentation, with an AFP of > 10,000, HCG of 8.1, and LDH of 286. CT of chest, abdomen, and pelvis was negative for any metastatic disease. He underwent a right inguinal radical orchiectomy with concomitant right scrotal exploration and scrotoplasty due to involvement of scrotal wall with tumor. Final pathology revealed a 10 cm yolk sac tumor extending to the scrotal skin (pT4) with no lymphovascular invasion identified. Tumor markers declined appropriately post-operatively. Patient was referred to Hematology-Oncology, who recommended adjuvant chemotherapy given the patient’s large tumor size with scrotal violation and intraoperative tumor spillage and significantly elevated pre-operative tumor markers. Conclusion: To our knowledge, there have been no reported cases of pure adult yolk sac tumor presenting as invasion into the scrotum. Given the rarity of advanced T-stage pure yolk sac tumor in adults, no consensus exists on post-orchiectomy therapy for such a condition. The literature suggests that patients with scrotal violation are not advised to undergo surveillance, but rather, opt for RPLND or chemotherapy, the latter of which our patient elected. *Not CME Accredited

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Notes

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NCS 87th Annual MeetingOctober 8 – 12, 2013Ritz Carlton NaplesNaples, Florida

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