Optimizing the Pedicled Latissimus Dorsi Myocutaneous Flap in Breast Reconstruction: Lessons Learned from 110 Consecutive Flaps

Background

The pedicled latissimus dorsi myocutaneous flap (LDMCF) in autologous breast reconstruction has been superseded by abdominal free tissue transfer. Common complaints of the LDMCF include the asymmetric back scar, need for prosthesis, and high seroma rates. We believe that the LDMCF remains versatile, with distinct advantages over other autologous options: the flap can be harvested unilaterally or bilaterally, not 'burning any bridges' for future reconstruction in unilateral breast reconstruction; the recovery is relatively easy, without complications such as risk of long-term abdominal wall weakness; and the aesthetic results are comparable, if not superior, leading to a more "youthful" result.

Methods

We performed a retrospective review over an 8-year period.

Results

A total of 106 patients underwent 110 breast reconstructions. Complications included four of 106 patients (3.8%) with seroma, three of 78 (3.8%) with periprosthetic implant infection, and one case of partial flap loss.

Conclusions

We learned the following: (1) Direct-to-implant can be performed in most LDMCF patients, avoiding the use of tissue expanders; (2) High BMI patients may not require an implant; (3) Back donor site aesthetics can be improved using a "bra-line-back-lift" approach; (4) Use of liposomal bupivacaine intercostal blocks and modified enhanced recovery after surgery protocol can reduce length-of-stay to overnight; (5) We achieved low seroma rates using topical fibrin glue and closed suction drains; (6) Low and high BMI patients who may not qualify for free tissue transfer are usually still surgical candidates with LDMCF; and (7) Short and long-term recovery are faster than free tissue transfer, with minimal long-term deficit.

Multi-institutional review of non-hypospadiac penile urethral stricture management and outcomes

OBJECTIVES

Penile urethral stricture disease not associated with hypospadias is rare, and there is a wide range of commonly used surgical repair techniques for this disease. We sought to compile a multi-institutional database of patients who had surgical correction of strictures in the penile urethra not limited to the meatus, and who had no history of hypospadias, for analysis using the Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology classification system.

METHODS

A retrospective database from 13 institutions was compiled of patients who had undergone surgical correction of Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology urethral stricture segments S2b/S2c and excluding E5, with a minimum follow-up time of 4 months. Failure was defined as cystoscopically confirmed recurrence of a stricture measuring less than 16-Fr.

RESULTS

We analyzed 222 patients with a median age of 57 years and a follow-up of 49 months. The overall surgical success rate was 80.2%. On multivariate analysis, the two variables identified that were predictive of surgical success were stricture length ≤2 cm as well as use of a buccal mucosa graft as compared to use of a fasciocutaneous flap, which had success rates of 83% and 52%, respectively (P = 0.0004). No statistically significant differences were found based on incisional approach or surgical technique, nor were outcomes different based on etiology or preoperative patient demographics.

CONCLUSIONS

Surgical repair of penile urethral strictures of non-hypospadiac origin have a favorable overall success rate, at 80.2%. Regardless of incisional approach or surgical technique, all operations appear to have similar outcomes other than repairs using fasciocutaneous flap, which were statistically less successful than those using buccal mucosa graft.

Simplified posterior urethroplasty utilizing laparoscopic instrumentation

Background

Posterior urethral stricture disease presents challenges for even the most skilled reconstructive urologists. Regardless of the surgical technique used, these are complex operations that occur in hard-to-access locations. We describe the use of a novel combination of laparoscopic instrumentation to simplify posterior urethral reconstruction.

Methods

We retrospectively identified patients undergoing a posterior urethral stricture repair utilizing a combination of the RD-180^® suture device and the Securestrap^®. These procedures were performed by a single surgeon at our institution. Patients with greater than or equal to 4 months of follow up were included in the analysis.

Results

From October 2016 to October 2020, 20 patients underwent posterior urethral stricture repair using these laparoscopic instruments. Median age was 70 years (28–90 years). Median follow up was 12 months (5–50 months). Mean stricture length was 3 cm (1.5–16 cm). Median operative time was 150 minutes (120–180 minutes). No peripheral neuropathies or positional injuries were noted. With failure defined as inability to pass a 16-Fr scope, success rate was 95% (19/20 patients).

Conclusions

The combination of the RD-180^® and the Securestrap^® has become essential to our posterior urethral stricture repair armamentarium. Further data and longer follow up is needed to confirm these reliable outcomes.

Complications Based on Prostate Size After Plasmakinetic Enucleation of the Prostate

BACKGROUND Lower urinary tract symptoms among adult men can significantly impact quality of life. We evaluated complications based on prostate size following plasma kinetic enucleation of the prostate. METHODS Patients were grouped into small prostate group (SPG) <75 grams, and large prostate group (LPG) >75 grams based on preoperative imaging. Patient demographics, comorbidities, preoperative international prostate symptoms score (IPSS), bother index (BI), prostate specific antigen (PSA) if indicated, post void residual volume (PVR), indwelling catheter or self-catheterization status, and any prior surgical intervention were evaluated. Postoperatively IPSS, BI, and PVR was assessed at 6 weeks, 4 months, and yearly. Post-operative urge urinary incontinence (UUI), stress urinary incontinence (SUI) and pad use was assessed. RESULTS Between September 2015 and December 2020, 296 bipolar enucleation with minimum 4 month follow-up were evaluated. All postoperative IPSS, BI, PVR and PSA timepoints were significantly decreased compared to pre-operative values (p <0.05). There was no significant difference in the complications between groups. Univariable and multivariable analysis found size <75 grams was predictive of stricture formation and bladder neck contracture. UUI was more common at 6 weeks in the SPG, and SUI was more common at 6 weeks in the LPG, but no difference was noted at the 4 month and 1 year time point. Pad use was equal between the two groups at all time points. CONCLUSIONS PKEP provides an effective treatment option for all prostate sizes, however, prostates <75 grams have a higher rate of BNC and urethral strictures compared to those >75 grams.

Predictors of Storage Symptom Improvement After Plasma Kinetic Enucleation of the Prostate

OBJECTIVE

To investigate which preoperative findings portend poor improvement in storage symptoms in patients undergoing plasma kinetic enucleation of prostate (PKEP).

METHODS

A single surgeon series of patients who had undergone PKEP with minimum 1 year follow up were evaluated. Patients were grouped into those with less than 33% improvement in storage symptoms (LIS) according to the international prostate symptom score (IPSS) and those with greater than 33% improvement in storage symptoms (GIS). Pre and postoperative factors were evaluated, along with IPSS, storage symptoms percentage (the total from frequency, urgency and nocturia divided by the total IPSS), bother index, and post void residual (PVR) at 6 weeks, 4 months, and yearly.

RESULTS

Two hundred sixty-eight patients had a minimum 1 year of follow up and had completed the IPSS. IPSS and bother index improved significantly from preoperatively to all time points post operatively in both groups, but the difference was greater in the GIS group. Patients in the GIS group had significantly larger prostates, more prostatic ingrowth, higher preoperative PVR, and a higher overall IPSS compared to the LIS group. Those in the LIS group had a higher incidence of prior prostate surgery, and a higher BMI. However, storage symptom percentages were equal between the GIS and LIS groups at all time points.

CONCLUSION

Greater prostatic ingrowth, larger prostate volume, higher preoperative PVR volume, and a higher overall IPSS was associated with greater improvement in storage symptoms. Prior prostate surgery and higher BMI portend less improvement in storage symptoms.

Virtue male sling outcomes and application to a contemporary nomogram

INTRODUCTION To report outcomes of our Virtue male sling series and evaluate predictors of surgical success and failure. We also retrofit the Male Stress Incontinence Grading Scale (MSIGS) refined nomogram, including the standing cough test (SCT), to assess its application to our cohort.

MATERIALS AND METHODS

A retrospective review was completed at a single institution over a 4 year period of all Virtue male slings implanted for stress urinary incontinence (SUI). Patient demographics including pad usage per day (PPD) and MSIGS were obtained on all patients after their bladders were filled cystoscopically. Failure was defined as > 1 PPD and/or conversion to another anti-incontinence procedure. Incidence, management and outcomes of complications were also evaluated.

RESULTS

Forty-six men who underwent Virtue male sling at a median follow up of 15.6 months were analyzed with an objective success rate of 78% and a subjective success rate of 85%. Preoperative predictors of surgical success were ability to stop stream on physical exam, lack of total incontinence and no history of posterior urethral stricture. MSIGS alone was not predictive of sling success or failure. Penile numbness occurred in 11% of patients and reoperation with incision of the sutured together transobturator arms improved sensation in all patients.

CONCLUSION

Virtue male sling has high objective and subjective success rates with a manageable side effect profile. Evidence of residual sphincteric function appears to be more predictive of sling success rather than MSIGS.

Abstract 1312: Identifying the genomic correlates of clinical benefit (CB) from immunotherapies (IO) and vascular endothelial growth factor-tyrosine kinase inhibitors (VEGF-TKI) in metastatic renal cell carcinoma (mRCC)

Background: Along with the expanding treatment landscape of mRCC, a substantial need for ways to predict individual patients' (pts) benefit from different therapies has emerged. Recent studies highlight the clinical significance of tumor-specific genomic alterations, revealing a prognostic and/or predictive role of PBRM1 mutations with IO in mRCC (Miao et al Nature 2018). Employing a large institutional database, we aimed to identify genomic correlates of CB from IO and VEGF-TKIs in mRCC. Methods: Consecutive pts who underwent genomic profiling (GP) as part of routine clinical care at the City of Hope Comprehensive Cancer Center were retrospectively identified. GP included the GEM ExTra assay, a clinical tumor-normal whole exome sequencing and tumor whole transcriptome sequencing test performed at Ashion Analytics (Phoenix, AZ), a CAP-accredited, CLIA-certified laboratory. The clinical database included detailed information regarding demographics, treatment, response and survival outcomes. Pts who had complete response (CR), partial response (PR) or stable disease (SD) for &gt;6 months were considered as having CB. Progressive disease (PD) as best response was considered no clinical benefit (NCB). Genomic findings were compared between pts with CB and NCB in the IO and VEGF-TKI cohorts. Results: Among the 58 (45:13 M:F) pts, 17 received sequencing treatment involving both a VEGF-TKI and IO, resulting in 32 pts in the IO cohort and 43 pts in the VEGF-TKI cohort. The most commonly used IO and VEGF-TKIs were nivolumab (59%) and sunitinib (40%). CB rate and median progression free survival were 59.4% (CR: 3.1%, PR: 18.8%, SD: 37.5%) and 15.6 months (95%CI NR-NR) in the IO cohort, and 86% and 14.2 months (95%CI 9.0 - 18.5) in the VEGF-TKI cohort. The most frequently detected alterations in the overall cohort were in VHL (64%), PBRM1 (38%), SETD2 (24%), KDM5C (17%) and TERT (12%). Interestingly, TERT promoter mutations and PBRM1 mutations were found to be mutually exclusive. In both IO and VEGF-TKI cohorts, tumor mutational burden did not differ between CB and NCB pts. No single genes were significantly associated with CB from VEGF-TKIs. While PBRM1 loss of function (LOF) was more common in IO pts with CB, and SETD2, KDM5C, TP53 alteration were more common in IO pts with NCB, there was no statistical significance observed (p values &gt; 0.05). TERT promoter mutations were associated with NCB in the IO cohort (p=0.038). TERT promoter mutant tumors did not have CB with IO. Conclusion: Our analysis found that TERT promoter mutations are enriched in pts with NCB from IO and were mutually exclusive with PBRM1 LOF which had previously been shown to be an indicator of IO sensitivity. These results suggest that TERT promoter mutations may be a negative predictor of IO outcomes, which warrants future investigations with a larger sample size.

Citation Format: Nazli Dizman, Sara Byron, Yung Lyou, Paulo Gustavo Bergerot, JoAnn Hsu, Andre-Philippe Sam, Denise Phan Trieu, Jeffrey Trent, Sumanta Kumar Pal. Identifying the genomic correlates of clinical benefit (CB) from immunotherapies (IO) and vascular endothelial growth factor-tyrosine kinase inhibitors (VEGF-TKI) in metastatic renal cell carcinoma (mRCC) [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1312.