EAU REVIEW 2014

Christopher French MD FRCSC

TOPICS OF INTEREST
Percutaneous Nephrolithotomy
Bleeding in Lap Partial Nephrectomy
Prostate Cancer: When to use adj RT
Testicular Cancer
Robotic ureteroscopy and other technology
GUYS 1-SINGLE STONE, SIMPLE
ANATOMY

GUYS 2-MULTIPLE STONES, OR POOR
LOCATION

GUYS 3-MULTIPLE STONES WITH
COMPLEX ANATOMY, CALYCES DIVER
TIC OR PARTIAL STAG HORN

GUYS 4- STAG HORN, OR ANY
PATIENT WITH SPINA BIFIDA / SCI
Guys Score for Stones
GUYS SCORE/PCNL COMPLEXITY
Developed for its simplicity and by reviewing literature
Lots of modern studies on its validation
Keys are that as Complexity increases, success rates fall and complications rise
Repeat access and ancillary procedures increase with score
Can provide a guide to manage patient expectations
MINI PCNL
Europeans love to present this
My experience 10 cases, 18F sheath and flex 16F scope
As perc tract size decreases so does utility of access
10F tracts discussed, IMO, too small.
PCNL
Mini Perc, limitation in dedicated sheaths, application in peds
Discussion around Standard PCNL prone vs Modified Supine
Need high selectivity of cases for supine. Many cases will need prone due to
stone position and anatomy
Only a few centers doing it.
Advantages for anesthesia, access to urethra.
Maybe for surgeons only doing PCNL
Outpatient Percs, Canadian driven.
Laparoscopic Partial
Nephrectomy
Bleeding Implications
LAP PARTIAL BLEEDING

HOPKINS ALGORITHM

LAP PARTIAL BLEEDING
Clamping vs No Clamping No difference
Suturing of deep tissue appears to be best
Delayed Bleeding (AVF vs PsuedoAn)
Hopkins Algorithm, trial of observation 24hrs
PARTIAL NEPHRECTOMY
Simple Tumor Eneucleation
Superselective microdissection
Trifecta: Warm ischemia <25min/NEG Margins/No Compl
1075 matched patients
Standard PN lower Margin rates vs STE
PARTIAL NEPHRECTOMY
Lots of studies on Clampless technique
Not standard but trendy
some large studies with 10year experience
fascilitated by CO2 compression
12 ideal, 20 for short periods, not standardized
500 case series
OR time 60min, 4cm or less, 12% complication rate, 3day stay
PARTIAL NEPHRECTOMY
Take aways
Cold dissection of tumor
fine monofilament closure of bed
Sliding clip closure of defect, no need to tie knots
Clamp vs clamp less is more Lap dependant
Trends towards superselective micro dissection
complications becoming standardized
Implications for 30d anticoagulation 2% delayed bleeding higher than VTE risk
all tumors less than 4cm?
MONTREAL STUDY: KARAKIEWICZ
ADJUVENT RT POST RRP WITH POS MARGIN
IMPROVES BCR (PSA RECURRENCE)
CANCER SPECIFIC SURVIVAL IS STILL CONTROVERSIAL.


7616 PTS WITH T3/T4 N0/1 PROSTATE CANCER
SEER

PATH RISK SCORE
T3B/GLEASON 8/LNI

IF LESS THAN 2 THEN RT DOES NOT IMPROVE MORTALITY

NNT =10 PATIENTS FOR >2 RISK FACTORS

SUGGESTS THAT MARGIN STATUS IN T3 GLEASON 7 OR
LESS WITH NO LNI OR SVI, NOT INDICATIVE OF NEED FOR
ADJ RT.


Prostate Cancer:
When to Radiate after surgery
RADS POST RAD PROSTATE

RADS POST RRP
Risk Scores in development post RRP and needed given surgery for high risk disease increasing.
Margin Status may be less important in decision process as compared to pathology characteristics, T3B, Gl8,
LNI
Do All margin pos patients need aRT? No!
Biochemical DFS is not Cancer Specific Mortality
Does LNI represent aggressive tumor biology or late detection? We feel T3B and high Gl Score do!
Radiotherapy studies post RRP have inherent bias through inclusion of low risk scores when main criteria is
margins.
Only 26% or 1/4 T3 Cancers post RRP meet criteria for statistical mortality decrease with aRT with a need to
treat of 10 to prevent one prostate cancer death
This is from SEER database (>7000 cases)

TESTES CANCER
CT threshold for nodes 4mm
implications for accurately Dx stage 1
No role for PET in Non Sems
Post Chemo CT
40% teratoma in NS vs 10% teratoma in sem
Surveilance, and CT risk of malignancy
100mservant threshold increases risk of malig
one CT 17mservant supporting post chemo surgery instead of long surveillance
ROBOTIC URETEROSCOPY
Development of dedicated ureteroscopy robot
First introduced 2011
Increased mobility within kidney,
Better flow
wide angle view
Infomercial




Technology
DOUBLE
TITANIUM
CLIP

Technology
Technology