Abstracts from the New England Section of the AUA 2020: A Virtual Experience

NE AUA 2020 Abstracts The Robotic Buccal Mucosa Graft Ureteroplasty Matthew J. Moynihan, MD, MPH , David Canes, MD, Alex J. Vanni, MD, Alireza Moinzadeh, MD, MHL Lahey Clinic, Burlington, MA Introduction: Radiation-induced urethral stricture disease (R-USD) creates surgical challenges for the reconstructive urologist due to the high risk of stricture recurrence and postoperative urinary incontinence (UI). We reviewed the outcomes of such patients at our institution to determine if conservative management can be an effective strategy. Materials & Methods: We retrospectively identified patients with R-USD who were managed with observation, endoscopic management, and/or clean intermittent catheterization (CIC). Any patient who had an obliterative stricture, underwent urethral reconstruction, or had less than 3 months follow-up was excluded. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, post void residual (PVR), and UI status. Secondary outcome measures were Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM), Sexual Health Inventory for Men (SHIM), andMale Sexual Health Questionnaire (MSHQ) scores. Results: Atotalof61menmet inclusioncriteriabetween2007-2019,withamedianfollow-up of 23.4 months (IQR 8.4-40.3). Median age was 77.9 years, body mass index was 27.1 kg/m 2 , andCharlsoncomorbidityindexwas6.Theindicationforpelvicradiationwasprostatecancer in95%andcolorectalcancer in5%.Thevastmajorityreceivedexternalbeamradiation(70%) or brachytherapy (28%). Of those with prostate cancer, 93% received radiation as primary therapyand7%receivedadjuvantorsalvageradiation.Therewerenosalvageprostatectomies in this cohort. Median stricture length on urethrogram imagingwas 2 cm (IQR 2-3). Stricture locationwas:bulbar(31%),bulbomembranous(49%),andprostatic(20%).Themostcommon urinary symptoms were slow flow (57%), urgency/frequency (26%), and nocturia (21%). A total of 51 (83%) patients underwent subsequent urethral dilation and 20 (33%) underwent subsequent direct visual internal urethrotomy (DVIU). Median number of dilations and DVIUs per patient was 3 (IQR 1-7) and 1.5 (IQR 1-3), respectively. CIC was utilized in 39% of patients. Six (10%) patients had anAUR episode requiring urgent treatment and 27 (44%) had a stricture-related UTI. Median serum creatinine, PVR values, and questionnaire scores remained stable between first and last visits (Table 1). UI was reported in 49% of patients at first visit and 57% at most recent visit. Median number of pads per day minimally changed (1 vs. 2) and median number of diapers per day remained stable (1 vs. 1). Conclusion: Although certain patients will desire urethral reconstruction, many patients with R-USD appear to be safely managed with conservative management with minimal effect on UI. Close observation is warranted due to the risk of stricture-related UTIs and AUR episodes. 28 29 Prostatic Urethral Lift: Does Age Matter? Mohannad A. Awad, MD , Richard D. Hartnett, MD, Erin Hunt, MS4, Andrew C. Mahoney, MD University of Vermont Medical Center, Burlington, VT Introduction: Complex ureteral reconstruction for stricture disease with buccal mucosa graft (BMG) is reported in the urologic literature with a number of case series touting its success for long-segment ureteral strictures that would otherwise require an ileal ureter or autotransplant. To date, there are approximately 34 reported human cases of robotic-assisted buccal ureteroplasty. However, the prior reports have varying definitions of operative success. We sought to review our single-institution experience with robotic- assisted BMG ureteroplasties to complement the existing literature. Materials&Methods: An institutional reviewboardapprovedobservationalretrospective review of all robotic ureteroplasties performed with a BMG at our institution by two surgeons was undertaken. Patient demographics, operative characteristics, and post- surgical outcomes were recorded. Clinical failure of the ureteroplasty was defined as the need to perform any additional intervention on the ipsilateral collecting system secondary to refractory ureteral obstruction. Results: A total of nine robotic BMG ureteroplasties were performed at our institution from 2015-2019. The stricture etiologies were iatrogenic endoscopic calculus treatment sequelae (n = 3), failed pyeloplasty (n = 3), idiopathic (n = 1), sequelae of nephrolithiasis (n=1), and iatrogenic ureteral injury during colorectal surgery (n = 1). All ureteroplasties were performed robotically, with six using an anterior onlay technique and three using an augmented anastomotic technique. Four of the patients had previously undergone a failed prior procedure for their stricture. The average ureteral stricture length in the cohort was 5.4 cm (4-7 cm). The stricture location was proximal for five cases while four cases were mid-ureteral. In seven cases the onlay graft was wrapped with an omental flap and in two cases the reconstruction was wrapped with only Gerota’s fascia. With an average follow up of 15.6 months (1-23 months), three (33%) of the BMG ureteroplasties required an additional intervention secondary to clinical failure of the reconstruction. Two of these cases had previous open ureteral reconstruction attempts. Of the failed reconstructions (cases 4-6), one required short term placement of a nephrostomy tube, one has required a chronic ureteral stent, and one underwent an autotransplant. Conclusions: The BMG ureteroplasty is an important addition to the armamentarium of surgical approaches for the management of ureteral stricture disease and is a viable treatment option for long segment ureteral strictures that would otherwise require an ileal ureter or autotransplant. Our small experience adds almost 25% case volume to the existing literature. Our success rate of 67% is notable lower than a previously reported multi-institutional review of 19 patients showing a 90% success rate published by Zhao et al (Eur Urol. 2017), but comparison is hindered by our limited case volume. We hope our experience encourages continued evaluation of this method as an efficacious option moving forward. Comparison of Magnetic Resonance Imaging to Transabdominal and Transrectal Ultrasound for Sizing of the Prostate Samuel Helrich, BS 1 , Nishant Garg, MD 1 , Wesley Pate, MD 1 , Philip Barbosa, MD 2 , Shaun Wason, MD 1 1 BostonUniversitySchoolofMedicine,Boston,MA; 2 BethIsraelDeaconessMedicalCenter,Boston,MA Introduction: Prostate size is an important factor when considering diseases of the prostate.AUAguidelines (2018) for surgical management of benign prostatic hyperplasia (BPH) now include consideration of prostate volume measurement prior to surgical intervention. Multiple imagingmodalities exist to estimate size, including transabdominal pelvic ultrasound (PUS), transrectal ultrasound (TRUS), and cross-sectional imaging with computed tomography(CT)andmagneticresonance imaging(MRI).Ultrasound isaquick, inexpensive, and accessible imagingmodality. MRI has been used increasingly in detection and diagnosis of prostate cancer and provides more accurate measurement of prostate size. This study seeks to compare PUS and TRUS to MRI in estimation of prostate size. Materials & Methods: We performed a single-center, retrospective study of 95 patients with PUS, TRUS, andMRI prostate sizing betweenAugust 15, 2013 and June 20, 2017 with IRB approval. Prostate volumes were derived from ellipsoid volume calculation (length x width x height x π/6). Correlation between MRI versus TRUS and PUS was calculated through the Pearson coefficient (PC). Reliability between each of the three modalities was analyzed through intraclass correlation coefficient (ICC). Agreement was assessed using Bland-Altman (BA) analysis, which is a visual representation of howmuch of the data falls between clinically defined limits of agreement (LOA) that we defined as ±10 cc. Data was further stratified by numerous other variables, including prostate size. Results: A total of 95 patients had MRI, TRUS, and PUS. Median age was 64, median BMI was 27 kg/m 2 , and median PSA value prior to PUS was 7.1 ng/mL. Nineteen (20%) were white,42(44%)wereblack,and21(22%)wereHispanic.Meandifference involumeestimate betweenMRIandTRUS(Vol TRUS -Vol MRI )was(6.1±15.5)cc,andmeandifference involume estimate between MRI and PUS (Vol PUS - Vol MRI ) was (5.5 ± 16.6) cc. PC for MRI vs. TRUS and MRI vs. PUS was 0.80 and 0.74, respectively. The ICC for all three modalities was 0.90 (0.86-0.92). BA analysis for MRI vs. PUS and MRI vs. TRUS showed that for prostates ≤ 50cc, greater than 80% of the data fell within the LOA. These percentages decreased with increased prostate size to 39% and 42% for prostates > 50cc and ≤ 80cc and to 25% and 61% for prostates > 80 cc for MRI vs. PUS and MRI vs. TRUS, respectively. Conclusions: MRI may be considered clinically interchangeable with TRUS and PUS for prostate sizing at prostate volumes ≤ 50cc, as BAanalyses showed good agreement between imaging modalities in this range. PUS and TRUS remain good tests in initial assessment of prostatesize.Ifminorchanges inprostatesizewoulddrasticallyaltersurgicalmanagement, we would not recommend US as the sole imaging choice. It is important to note that our conclusions are based on our LOA of ±10cc, and this may vary based on clinical scenario and provider comfort. When selecting modality for prostate sizing, one should consider all factors including the benefits and drawbacks of each type of imaging. 27 13 Scientific Session III: BPH/Recon