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BackgroundPelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI.MethodsTwenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction.ResultsThere were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784).ConclusionIn this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter.Level of evidenceTherapeutic/Care Management; Level III.

BACKGROUND Bladder injuries often occur in the setting of polytrauma, and if severe, may require open surgical repairs. We assess the role of urologists and general surgeons (GS) in the open surgical management of bladder injuries and their outcomes in a traumatic setting. METHODS Patients who underwent open bladder injury repair secondary to trauma from 2000 to 2017 by urology or GS were identified in the Pennsylvania Trauma Outcome Study database by International Classification of Diseases-9th Rev.-Clinical Modification procedure codes (57.19-57.93). Patient demographics, initial trauma assessment, length of hospital stay, associated complications, and mortality were evaluated. Urology management of a bladder injury was defined by documentation of a urologist in the operating room or urological consultation during the hospital stay. GS management was defined by documented bladder repair without urology involvement as described previously. RESULTS Of 624,504 patients in the database, 701 met inclusion criteria (419 managed by urology, 282 by GS). The most commonly performed procedure was suturing of bladder lacerations (80.5%). On univariate analysis, GS was more likely to manage patients with penetrating injuries and those who required exploratory laparotomy less than 2 hours upon arrival. Urology was more likely to manage patients with concomitant pelvic fractures and higher Injury Severity Score (ISS). On multivariate analysis, higher ISS was predictive of urology management (odds ratio, 1.83; 95% confidence interval, 1.17-2.87, p = 0.008), while patients who required urgent exploratory laparotomy was predictive of GS management (odds ratio, 0.34; 95% confidence interval, 0.21-0.55, p < 0.001). Patients with concomitant pelvic fractures (n = 318) were also more likely to have higher ISS (p < 0.001) and were more likely to be managed by urology (odds ratio, 1.52; 95% confidence interval, 1.01-2.30, p = 0.046). Mortality, length of hospital stay, and complication rates were not significantly different between the two specialties and among individual procedures. CONCLUSION Our study describes the landscape of traumatic bladder repairs between urology and GS. GS may maintain similar patient outcomes when managing select cases of traumatic bladder injuries in the absence of urologists. LEVEL OF EVIDENCE Therapeutic, level IV.

Objective To describe our surgical experience for the treatment and management of extramammary Paget's disease (EMPD). Methods Our surgical approach involves excising a 2-cm margin of normal appearing skin around the EMPD-suspicious lesion. Prior to excision, the tissue is oriented and demarcated into predefined segments in coordination with a pathologist. Frozen sections are performed when necessary to guide additional excision. Xenograft or wet-to-dry dressings are applied depending on size and location of the wound while the specimen is expeditiously reviewed over the following 24-48 hours. If positive margins remain, further excision of the corresponding skin segment is performed. Delayed complex wound closure +/− split thickness skin grafting is performed once negative margins are confirmed. Results Ten EMPD patients were referred to two academic centers between 2014 and 2018. Two patients had positive lymph nodes at diagnosis and underwent palliative surgery and died within 12 and 29 months. The remaining 8 patients underwent a median of 1 surgery (range 0-3) with referring providers before undergoing a median of 3 surgeries (range 2-5) at our institutions to achieve negative surgical margins and wound reconstruction (7 split thickness skin grafts, 1 secondary closure). At mean follow-up of 15 months, 1 patient recurred, required further excision, and remains disease free. Conclusion EMPD is a rare malignancy with poorly described treatment methodologies. Due to its multifocal distribution and asymmetric spread, obtaining negative margins can be challenging. Our systematic approach to obtaining wide margins and documenting excised skin has enabled us to achieve negative margins for this challenging malignancy.

Author(s): Chung, Paul H; Vanni, Alex J; Breyer, Benjamin N; Erickson, Bradley A; Myers, Jeremy B; Alsikafi, Nejd; Buckley, Jill; Elliott, Sean P; Zhao, Lee C; Voelzke, Bryan B; Trauma and Urologic Reconstructive Network of Surgeons (TURNS) | Abstract: ObjectiveTo compare the utility of generic health quality of life (QOL) and condition specific indicators as patient reported outcomes measures for urethral stricture surgery.Materials and methodsPatient data were obtained from the Trauma and Urologic Reconstructive Network of Surgeons collaborative database. Patients who underwent any successful urethroplasty and completed both pre- and postoperative generic and condition-specific questionnaires were included.ResultsA total of 201 patients met inclusion criteria. Urethral-stricture specific measures improved after surgery: mean LUTS score (13.1-4.0, pl0.05), Peeling curve (3.1-1.7, p l 0.05), and overall interference of urinary symptoms on life (3.0-1.6, p l 0.05). Mean overall health status visual analog scale (74.2-80.0, p l 0.05) and generic health QOL EQ-5D index scores (0.90-0.95, p l 0.05) also improved; however, individual EQ-5D measures assessing mobility, self-care, and activity level did not change. EQ-5D measures for pain/discomfort (1.48-1.23, p l 0.05) and anxiety/depression (1.33-1.21, p l 0.05) improved, but not to the same extent as stricture-specific measures. More patients reported improvement in condition-specific urethra/penis pain and bladder pain compared to improvement in generic EQ-5D pain/discomfort (p l 0.001).ConclusionGeneric health QOL indicators are less meaningful in the assessment of urethral stricture surgery and should be replaced with condition-specific outcomes measures. It is important to ensure that appropriate condition-specific outcomes measures are utilized as patient reported outcomes measures become more prevalent in medicine and potentially become utilized to evaluate surgeon outcomes and determine surgeon reimbursement.

Utilizing a physician-reported survey, we assessed general surgeons (GS) comfort level in the management of bladder trauma, from a GS and urologist's perspective.Online questionnaires were distributed electronically to physicians of the American College of Surgeons and American Urological Association. This survey queried demographic data, clinical factors that may influence urology consultations, and bladder injury scenarios of varying severities. Two questions were presented for each scenario, the first querying GS comfort level in bladder trauma management, the second assessing the likelihood of obtaining urology consultations in such scenarios. Responses were graded on a Likert scale.Overall, 108 (51%) GS and 104 (49%) urologists responded. When compared to managing Grade I injuries, the comfort level of GS decreased as the severity of bladder trauma increased, while the likelihood of obtaining a urology consultation increased. While the perceived comfort of GS by urologists decreased from 84% to 5% for Grade I to Grade V injuries, GS reported a significantly higher comfort level (Grade I: 92%, p = 0.09; Grade V: 31%, p0.001). Majority of GS indicated that preoperative diagnosis on imaging (56%), intraoperative diagnosis (62%), and timing of patient presentation (76%), did not affect their decision to consult urology for assistance in bladder trauma (p0.001).GS-reported comfort levels for bladder trauma management remains higher than urology-perceived comfort levels. Contrary to urologists' perception, most peri-injury factors did not affect GS decision to consult urology for bladder trauma. We hope this study can foster discussion and improve interdisciplinary collaboration in bladder trauma management.

INTRODUCTION AND OBJECTIVE:The ability to identify and quantitate peri-urethral fibrosis is limited prior to urethral stricture surgery. Shear wave elastography (SWE) is a quantitative and reproduc...

Objective To present our updated experience and discuss potential benefits of early endoscopic realignment (EER) for patients with pelvic fracture urethral injuries (PFUIs). Methods A retrospective review of patients treated with EER after blunt PFUIs was performed. EER was performed with a retrograde or a combined antegrade or retrograde approach with a cystoscope. Treatment success was defined as no secondary procedure or the ability to pass a cystoscope across the area of injury or surgical anastomosis. Results Thirty-two patients (mean age 38 years, range 17-73) underwent EER between 2004 and 2016 with a mean follow-up of 26 months (range 1-102). Median time to realignment was 2 days (range 0-6) and was performed concomitantly with another surgical service in 72% of cases. Median operative time for EER was 38 minutes (range 8-100). Using an intent-to-treat analysis, 29 patients (91%) failed EER. Nine patients underwent a subsequent endoscopic procedure with 22% success rate. Excision and primary anastomotic urethroplasty was performed in 24 patients as a primary or secondary treatment with 96% success rate. Conclusion Our overall success rate for EER was 9%, but did not hinder subsequent urethroplasty success. The decision for performing EER should not be based on success alone. Secondary benefits of EER exist and may assist with the multidisciplinary care of a patient with complex trauma. The management of PFUI is challenging and these patients should be referred to tertiary centers.

Objective To illustrate the heterogeneous care delivered to patients with extramammary Paget disease (EMPD), a rare and lethal malignancy with poorly described treatment methodologies, by characterizing the clinical and pathologic characteristics of an international patient support group. Materials and Methods Institutional review board approval was obtained to develop and distribute a nonvalidated survey to patients from an international, online EMPD support group. The survey was developed to capture patient clinical and pathologic details and was distributed between January 2017 and February 2017. Results Forty-two patients completed the survey. At a mean age of 64 years, patients most commonly developed rash, pruritus, or erythema in the genital and perianal regions. Patients presented to their primary care physician, gynecologist, or dermatologist and were initially treated with topical agents for benign diagnoses. After failing conservative treatments, patients underwent biopsy by a dermatologist or gynecologist and were diagnosed with EMPD on average 21 months after the onset of symptoms. Wide local and Mohs excisions were the most frequently administered treatments with positive margins reported in 43% of patients. Fewer patients underwent noninvasive treatment with imiquimod cream and radiation. In total, 29% of patients developed regional recurrence and distant disease. There was wide variation regarding medical specialties involved, diagnostic evaluation, treatment, and clinical follow-up. Conclusion This study provides a novel view of the varied clinical and pathologic details from patients treated across varying institutions and medical specialties. This study will hopefully educate providers of the overall disease process of EMPD and encourage the development of standardized treatment recommendations.

INTRODUCTION AND OBJECTIVES:Prescription opioids are a mainstay of postoperative pain management. We outlined the course and severity of postoperative pain in patients undergoing urethroplasty and ...

Injuries to the bladder are infrequent and commonly result from blunt, penetrating, or iatrogenic trauma. Bladder injuries may be missed as they often present concomitantly with other abdominal and pelvic injuries; however, early detection and treatment are essential as morbidity and mortality may be significant. Gross hematuria, especially in the setting of pelvic fractures, may be indicative of a bladder injury which can be confirmed with cystography. Extraperitoneal injuries are commonly managed conservatively with catheter drainage while intraperitoneal ruptures traditionally required surgical exploration and closure. Presented is a contemporary review which encapsulates the etiology, presentation, assessment, and management of bladder injuries.

Objective To compare the frequency and severity of erectile dysfunction (ED) among pelvic fracture patients with and without urethral injuries and to identify potential risk factors for ED in the setting of pelvic fracture injury. Materials and Methods A retrospective review was conducted of male patients treated for pelvic fractures with and without urethral injuries at a Level 1 trauma center between 2005 and 2016. The International Index of Erectile Function (IIEF-5) questionnaire was administered to patients by telephone to assess post-injury ED. Additional questions about pre-injury ED, post-injury symptoms, and past medical history were reviewed. Results Fifty patients (42%, n = 118) responded to the IIEF-5 questionnaire: 29 with pelvic fractures alone and 21 with PFUIs. We observed a numerical increase in frequency of new onset ED in patients with pelvic fracture urethral injuries (PFUIs) (n = 12, 57%) compared with patients with pelvic fractures alone (n = 11, 38%) (P = .3). Patients with PFUIs reported lower IIEF-5 scores (ie worse ED) than patients with pelvic fractures alone (13 versus 18, P = .05). There were no significant differences in potential risk factors between the 2 groups on univariate analyses. Conclusion ED was more severe following PFUI than pelvic fracture alone. We suspect that urethral injury is not the direct cause of ED, but rather a surrogate for extensive pelvic injury and risk for neurovascular injury. A larger prospective analysis is warranted to clarify this hypothesis and to further stratify risk factors for developing ED in pelvic fracture patients with and without urethral injuries.

Objective: Many patients who undergo inflatable penile prosthesis (IPP) replacement are often upsized to larger cylinders, suggesting the IPP may serve as a tissue expander and increase internal penile length. The objective of this study is to evaluate whether cylinder length increases with subsequent IPP insertion. Materials and Methods: We queried American Medical Systems and Coloplast Patient Information Form databases to identify patients who underwent IPP placement and replacement between 2004-2013. Patients were grouped by device type and time to replacement (0.5 cm and 40% demonstrated increases of ≥1 cm. Conclusions: As demonstrated, the IPP may provide tissue expansion over time. Further evaluation is needed to determine if increased cylinder length correlates to increased functional length and patient satisfaction.

Purpose: To report our initial results of robotic appendicovesicostomy (APV) revision in children. Patients and Methods: Three patients (median age 6 years; range 6–13) underwent robot-assisted APV surgery for bladder dysfunction because of posterior urethral valves, myelomeningocele, and traumatic spinal cord transection. Leakage developed in each patient from the APV. After failing more conservative treatments, the patients subsequently underwent robot-assisted APV revision. Results: Robot-assisted APV revision was conducted at a median 14 months (range 6–34 mos) after initial surgery. Median operative time was 165 minutes (range 106–232 min), and blood loss was ≤5 mL for all patients. Intraoperative findings ranged from partial to complete separation of the APV from the bladder tunnel. APV leakage resolved for all patients at last follow-up (median 5 months; range 2–9 mos). Conclusion: This initial series expands the scope of robotic surgical procedures in children. Robot-assisted APV revision...

Objective To report surgical and functional outcomes of buried penis surgery. Methods Outcomes following buried penis surgery at the University of Washington were assessed from June 1, 2005 to June 1, 2016. Patient demographic and surgical data were abstracted from a retrospective chart review. All patients were attempted to be contacted by phone for long-term follow-up. Uni- and multivariate analysis was performed to evaluate for association with any complication. Results A total of 42 men underwent buried penis repair surgery (mean short-term follow-up 8.1 months). There was an overall 33% 90-day complication rate (21 events). In univariate analysis, body mass index (BMI; P = .02) and no history of gastric bypass ( P = .03) were significant predictors of any complication. In multivariate analysis, only BMI remained significant (odds ratio 1.1 for each increase in unit of BMI, 95% confidence interval 1.01-1.27). Twenty-seven patients were reached for long-term follow-up (mean 39 months). Patients reported improvements in every functional domain that was assessed. Of the patients, 85% reported they would undergo buried penis surgery again, 74% that surgery led to a positive change in their lives, and 85% that the surgery had remained a long-term success. Conclusion Surgical correction of buried penis with penile split-thickness skin graft and limited panniculectomy is well tolerated and results in functional, long-term improvements. BMI is associated with an increased likelihood of a complication following surgery.

Lower urinary tract foreign bodies have been reported in both children and adults. It is helpful for urologists to review foreign body case reports to become familiar with alternative approaches for removal that may prove helpful during challenging cases. To our knowledge, we describe for the first time a degraded rare-earth magnet within the body and use of Hartmann ear forceps to remove a foreign body from the urethra under cystoscopic guidance through a limited urethrotomy.

To present a novel algorithm for definitive reconstruction of penile curvature in men undergoing inflatable penile prosthesis (IPP) surgery as an alternative to manual penile modeling and grafting procedures.Patients with erectile dysfunction and concomitant penile curvature undergoing IPP placement were divided into 2 treatment groups: (1) group 1, penile deformity known preoperatively, and (2) group 2, penile curvature recognized intraoperatively after IPP placement. Group 1 patients underwent penile plication after artificial erection and immediately before IPP insertion via the same penoscrotal incision, whereas group 2 patients were treated with a Yachia (Heineke-Mikulicz) corporoplasty over the intact cylinders. Patients completed postoperative Patient Global Impression of Improvement (PGI-I) questionnaires assessing overall satisfaction.Among 405 men receiving IPP at our institution from 2007 to 2014, 30 patients received synchronous correction of penile curvature (7%). Group 1 included 23 of 30 (77%) patients, and 7 of 30 (23%) were in group 2. Overall mean initial curvature was 36°, and all patients were corrected to10°. Average operative times were 18 minutes longer compared with patients who underwent IPP placement alone (82 vs 64 minutes, P.05). At an average follow-up of 13 months (range 7-32), 19 of 20 (95%) group 1 and 6 of 7 (86%) group 2 patients who completed surveys reported an improved overall condition. No patient reported chronic pain, recurrent deformity, or device malfunction.Penile curvature can be safely and reliably corrected at the time of IPP placement, regardless of whether the deformity was identified preoperatively.

Objective To present our updated experience and patient-reported outcomes of high submuscular (HSM) placement of urologic prosthetic balloons and reservoirs (UPBRs). Methods A retrospective review was performed of patients who underwent inflatable penile prosthesis and/or artificial urinary sphincter placement between 2011 and 2013. UPBRs were placed in an HSM location between the transversalis fascia and the rectus abdominis muscle by blunt dissection through the external inguinal ring via a trans-scrotal approach. Patient demographics, perioperative outcomes, and patient-reported outcomes were reviewed. Results During the study period, 146 patients received 158 HSM implants: inflatable penile prosthesis reservoirs (n = 93) or artificial urinary sphincter balloons (n = 65). Patients completed a standardized survey at a mean of 3.2 months (range, 1.1-23.4 months) after surgery and were last followed up at a mean of 5.5 months (range, 1.1-28.7 months). Overall, 94% (n = 149) of UPBRs caused no bother, and patients were satisfied with 96% (n = 151) of implants. Patients were unable to palpate 80% (n = 126) of UPBRs and minimally palpate 16% (n = 26). The primary surgeon was unable to palpate 72% (n = 115) of UPBRs and minimally palpate 20% (n = 31). Type of UPBR, body mass index, reservoir volume, and reservoir manufacturer were not associated with patient or surgeon palpability. Of the 158 UPBRs placed, only 2 (1.3%) were revised due to bothersome patient palpability. No bowel, bladder, ureteral, or vascular injuries occurred. Conclusion HSM placement of UPBR is safe and feasible, well tolerated, and avoids deep retropubic dissection. Patient-reported outcomes support low palpability, low bother, and high patient satisfaction.

Objective To compare the safety and efficacy of patients undergoing dorsal penile plication with patients undergoing ventral and lateral plication. Methods A retrospective review was performed of all patients who underwent penile plication between 2007 and 2013. Plication was performed through a 2-cm longitudinal incision in the proximal or midpenile shaft without degloving. Plication sutures were placed in parallel opposite the angle of greatest curvature. Dorsal plication was performed with minimal displacement of the neurovascular bundle. Patient demographics, perioperative outcomes, and patient-reported outcomes were analyzed. Results Of 215 patients who underwent penile plication, complete operative and patient-reported outcomes data were available for 118 (55%). Patients were grouped by location of plication: dorsal (n = 17 [14%]), ventral (n = 65 [55%]), and lateral (n = 36 [31%]). Mean age (52-58 years; P = .51) and preoperative curvature (36-51°; P = .78) were similar among the 3 groups. Each group required a similar number of sutures (8-9; P = .18) to achieve similar correction (37-45°; P = .33). Patients completed a satisfaction survey at a mean of 15 months (range, 1-41 months) after surgery. All groups reported equally high rates of satisfaction for penile curvature ( P = .64), penile rigidity ( P = .64), strength of erection ( P = .98), and overall satisfaction ( P = .75). Although each group reported subjective decrease in penile length ( P = .10), objective length loss occurred on a small scale (mean length loss for all groups, 0.3-0.8 cm; P = .24). Conclusion Penile plication is a safe and effective technique for correcting all directions of curvature. Dorsal plication without degloving produces favorable objective and subjective results comparable to ventral and lateral plication.

Twenty to thirty percent of patients with Peyronie's disease (PD) have erectile dysfunction (ED) refractory to medical therapy and may benefit from a combined procedure addressing both conditions.The aim of this study was to show the efficacy of inflatable penile prosthesis (IPP) insertion and synchronous penile plication for correcting penile curvature and ED in patients with PD.A retrospective review was performed of all patients who underwent IPP insertion with synchronous penile plication at our tertiary care center between 2010 and 2013. All patients received an intraoperative saline intracorporal injection to induce an artificial erection. After the tunica albuginea was exposed via a standard transverse scrotal incision over the proximal penile shaft, the incision was retracted distally and/or laterally as needed for plication suture placement. Plication sutures were placed in parallel opposite the angle of greatest curvature. The incision was returned proximally to the standard penoscrotal junction for IPP insertion. Demographic and surgical data were collected from the patients' medical records. Patient satisfaction was assessed postoperatively using a nonvalidated questionnaire.The focus of this study was surgical outcomes, both technical and patient-reported satisfaction.Eighteen patients with a mean age of 63 years underwent IPP insertion with synchronous penile plication. Patients presented with dorsal (n = 11), lateral (n = 2), and biplanar curvature (n = 5). Mean preoperative curvature was 39 degrees (range 30-60) and was corrected on average to5 degrees (range5-12) using a median of four plication sutures (range 3-6). Among 15 patients completing a postoperative satisfaction survey at a mean of 11 months, all reported improvement in their overall condition and penile curvature; one with biplanar deformity reported minor residual curvature. None reported continued pain or required suture release.IPP insertion with synchronous penile plication for the correction of ED and PD is effective and results in high patient satisfaction.

INTRODUCTION AND OBJECTIVES: The true reoperation rate of penile prosthetic surgery is unknown due limited data from retrospective, single institution studies. This study aims to evaluate the reoperation rate after virgin penile prosthetic surgery using a large population database METHODS: A longitudinal analysis of California Office of Statewide Health Planning and Development database from 1995 to 2010 was performed. Inclusion criteria were men who underwent their first penile prosthetic surgery. Patients were excluded if they had an explant of a prior prosthesis at the time of their first recorded surgery. Primary outcome was reoperation, specified as the removal or replacement of the prosthesis. Censoring events included penile amputation, surgeries of the genitalia or pelvis, and cancer involving the genitourinary organs. Statistical analysis was performed via KaplanMeier plot, hazard curve, and multivariate analysis adjusting for age, race, gender, comorbidities, insurance status, hospital volume and teaching status RESULTS: 7,666 patients (40,932 patient years) were included in the study. The 5 and 10-year cumulative reoperation rates were 11.2% (CI: 10.5-12.0%) and 15.7% (CI: 14.7-16.8%) respectively. Malfunction and infection accounted for 57% and 27% of reoperations. Reoperation rate was highest at 1 year post-operatively (3.4% per year), and steadily declined until 2 years post-operatively, after which it remained at roughly 1.25% per year. Multivariate analysis showed higher rates of reoperation among younger patients (HR1⁄41.51, CI: 1.122.05 for 75yo), African American patients (HR1⁄41.30, CI: 1.05-1.62), and Hispanic patients (HR1⁄41.32, CI: 1.121.57). 22.9% of the reoperations were performed at a hospital different from the initial implantation CONCLUSIONS: Reoperation rate for penile prosthetic surgery is highest in the first year postoperatively. The patients with highest risk for reoperation are African American, Hispanics, and younger age for unclear reasons that warrant further study. Nearly a quarter of reoperations occur at a hospital different from the initial surgery, suggesting that existing literature does not reflect the true prevalence of penile prosthetic complications

Objectives Minimally invasive robotic assistance is being increasingly utilized to treat larger complex renal masses. We report on the technical feasibility and renal functional and oncologic outcomes with minimum 1 year follow-up of robot-assisted laparoscopic partial nephrectomy (RALPN) for tumors greater than 4 cm. Materials and methods The urologic oncology database was queried to identify patients treated with RALPN for tumors greater than 4 cm and a minimum follow-up of 12 months. We identified 19 RALPN on 17 patients treated between June 2007 and July 2009. Two patients underwent staged bilateral RALPN. Demographic, operative, and pathologic data were collected. Renal function was assessed by serum creatinine levels, estimated glomerular filtration rate, and nuclear renal scans assessed at baseline, 3, and 12 months postoperatively. All tumors were assigned R.E.N.A.L. nephrometry scores ( http://www.nephrometry.com ). Results The median nephrometry score for the largest tumor from each kidney was 9 (range 6–11) while the median size was 5 cm (range 4.1–15). Three of 19 cases (16%) required intraoperative conversion to open partial nephrectomy. No renal units were lost. There were no statistically significant differences between preoperative and postoperative creatinine and eGFR. A statistically significant decline of ipsilateral renal scan function (49% vs. 46.5%, P = 0.006) was observed at 3 months and at 12 mo postoperatively (49% vs. 45.5%, P = 0.014). None of the patients had evidence of recurrence or metastatic disease at a median follow-up of 22 months (range 12–36). Conclusions RALPN is feasible for renal tumors greater than 4 cm with moderate or high nephrometry scores. Although there was a modest decline in renal function of the operated unit, RALPN may afford the ability resect challenging tumors requiring complex renal reconstruction. The renal functional and oncologic outcomes are promising at a median follow-up of 22 months, but longer follow-up is required.

525 Background: There have been multiple reports implicating the role of hydronephrosis (HN) as a predictor of outcome in patients diagnosed with upper tract urothelial carcinoma (UTUC). However, this was done in mixed populations (low-/high-grade) and degree of HN (DOH) was not taken into account. We evaluated the impact of severity of hydronephrosis on systemic and bladder relapse in patients with UTUC. Methods: We retrospectively reviewed the records of 141 patients with localized UTUC that underwent extirpative surgery. Preoperative imaging was used to evaluate ipsilateral DOH. We analyzed the association between DOH (none/mild vs. moderate/severe), pathological findings and oncological outcomes in high-grade vs. low-grade patients. Bladder recurrence was assessed separately from local or systemic (L/S) recurrence. Results: High-grade UTUC was present in 80% of patients, 35% had muscle-invasive disease (≥pT2), and 29% had non-organ-confined disease. At a median follow-up of 34 months (range, 1-149), 35% of patients experienced intravesical recurrence, 20% developed L/S recurrence, and 17% died of UTUC. No difference in outcomes was seen between patients without HN and mild HN. DOH was none/mild in 55% and moderate/severe in 45% of cases. In patients with high-grade UTUC, moderate/severe HN was associated with advanced pathologic stage (p