New multiport robotic surgical systems: a comprehensive literature review of clinical outcomes in urology

Over the past 20 years, the field of robotic surgery has largely been dominated by the da Vinci robotic platform. Nevertheless, numerous novel multiport robotic surgical systems have been developed over the past decade, and some have recently been introduced into clinical practice. This nonsystematic review aims to describe novel surgical robotic systems, their individual designs, and their reported uses and clinical outcomes within the field of urologic surgery. Specifically, we performed a comprehensive review of the literature regarding the use of the Senhance robotic system, the CMR-Versius robotic system, and the Hugo RAS in urologic procedures. Systems with fewer published uses are also described, including the Avatera, Hintori, and Dexter. Notable features of each system are compared, with a particular emphasis on factors differentiating each system from the da Vinci robotic system.

Ulceration in bladder cancer associates with extravesical disease, independent of cell cycle, or hypoxia pathways status: Integrating gross morphology and expression profiles in cystectomies

OBJECTIVE

Ulceration is common in bladder tumors, but its prognostic role, although intuitive, is not established. We aim to explore the presence of gross ulceration and its relationship with other morphological and biological features classically associated with extravesical disease, in patients submitted to radical cystectomy.

METHODS

Tumor size and morphology were noted on 101 cystectomy patients (2000-2010). Papillary, exophytic, and vegetant tumors were grouped as "papillary" and solid/nodular, ulcerated and infiltrative as "nonpapillary." Ulceration was noted grossly in every case as a binary parameter, regardless of morphology. Immunohistochemistry was performed for hypoxia (hypoxia-inducible factor-1α and vascular endothelial growth factor), and cell cycle proteins (pRb, p53, and cyclin D1).

RESULTS

Mean age was 66.7 year, male:female ratio was 2:1, 20 patients received bacillus Calmette-Guerin and 10 neoadjuvant chemotherapy. Upstaging rate was 56.4%. Ulcerated lesions presented mostly as nonpapillary and nonorgan confined (nOC), whereas nonulcerated tumors were often papillary and organ confined (OC). Tumor size was smaller in nonpapillary tumors (P = 0.002), but did not associate with altered hypoxia or cell cycle expressions. pRb and cyclin D1 loss and p53 overexpression were more frequent in ulcerated and non-OC tumors as did the phenotype vascular endothelial growth factor-negative/hypoxia-inducible factor-1α-low (P<0.001). On a multivariate model, ulceration was an independent predictor of non-OC and extravesical disease.

CONCLUSION

Patients with ulcerated tumors were often staged with extravesical disease, independent of other morphologic and biological features known to affect prognosis. Prospective studies are needed to confirm the predictive value of tumor ulceration at cystoscopy, which could improve patient stratification for neoadjuvant chemotherapy.

Abstract 2242: Comprehensive genome methylation and whole genome expression analysis in penile carcinoma: Uncovering new molecular markers

Background: Penile carcinoma (PeCa) is frequently associated with high morbidity rates. Unlikely of the vast majority of tumors, there is no molecular markers described that are able to assist in diagnosis and prognosis or with potential to be therapeutic targets in PeCa.

Patients and methods: DNA methylation status (244K Human DNA Methylation Microarray platform, Agilent Technologies) and large-scale expression analysis (4x44K Whole Human Genome Microarray, Agilent Technologies) were performed in 35 and 37 PeCa, respectively. Quantitative bisulfite pyrosequencing (qBP) and RT-qPCR were used to validate the findings in 93 samples. HPV status was assessed using the Linear Array HPV Genotyping kit (Roche Molecular Diagnostics, CA, USA).

Results: Methylome analysis revealed 171 hypermethylated and 449 hypomethylated CpGs sites and the transcriptome profiling showed 2986 down- and 2817 over-expressed genes. HPV positivity was found in 32.7% of the cases, mainly the HPV16. The integrative analysis in 32 PeCa revealed a panel of 96 genes with inverse correlation between methylation and gene expression levels. The CpG hypermetlylation and gene downexpression, was confirmed for TWIST1, RSOP2, SOX3, SOX17, CD133, OTX2, HOXA3 and MEIS. In addition, BIRC5, DNMT1 and DNMT3B presented low levels of methylation and overexpression. The comparison of the results with clinical findings revealed that LIN28A, NKX2.2, NKX2.3, LHX5, BDNF, FOXA1 and CDX2 were associated with poor prognosis features.

Conclusion: Putative prognostic markers were detected revealing that DNA methylation modulates the expression of several genes in PeCa. These data may prove instrumental for biomarker discovery in clinics and molecular epidemiology of PeCa.

Citation Format: Hellen Kuasne, Ilce Mara de Syllos Colus, Hector Hernandez-Vargas, Ariane Fernanda Busso-Lopes, Mateus C. Barros-Filho, Fabio A. Marchi, Christovan Scapulatempo-Neto, Eliney F. Faria, Ademar Lopes, Gustavo C. Guimaraes, Zdenko Herceg, Silvia R. Rogatto. Comprehensive genome methylation and whole genome expression analysis in penile carcinoma: Uncovering new molecular markers. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2242. doi:10.1158/1538-7445.AM2014-2242

Abstract 3327: Epidermal growth factor receptors and penile carcinoma: The role of EGFR and HER2 expression as prognostic and predictive markers

BACKGROUND: Growth factor receptors have recently been described as potential therapeutic targets for penile carcinoma patients, and there are reports on benefits from the clinical use of monoclonal antibodies against EGFR. However, knowledge on the molecular basis of the disease is scarce. For that, we have addressed the expression of EGFR and HER2, as well as mutational and amplification status of EGFR in samples from penile squamous cell carcinoma (PSCC) patients.

METHODS: Clinicopathologic features and survival data from 183 PSCC patients were reviewed from hospital records and immunohistochemistry (IHC) against EGFR and HER2 was performed. Positive cases were those showing strong and complete membrane staining in more than 10% of the tumor cells. HER2 was also classified as positive according to the presence of cytoplasmic staining (cHER2). Sixty cases were submitted to dual-color fluorescence in situ hybridization (FISH) and were classified as unaltered (those harboring 2 signals for each probe) or FISH positive (either if polysomic - harboring more than 2 signals for each probe - or amplified - cases with an EGFR signal:centromeric signal ratio exceeding 2). EGFR exons 18, 19, 20 and 21 from 27 independent frozen cases were sequenced. Variables were compared by the Pearson chi-square or Fisher´s exact test. Survival rates were calculated using the Kaplan-Meier method and compared by log-rank test. Alpha error was set at 5%.

RESULTS: IHC analysis showed that, for EGFR expression, 91 cases (49.7%) were positive and 92 negative, out of which 9 (4,9%) showed no staining at all. Positive cases were associated with higher incidence of recurrence and exophytic growth (p=0.031 and p=0.023, respectively). Membrane staining of HER2 was not seen in any case whereas cHER2 was found in 20.3% (29) of cases, all of them high grade tumors. No low grade tumor presented this staining pattern. cHER2 was also associated with EGFR expression (p=0.017). Regarding FISH, 36 cases were unaltered whereas 32 were FISH positive (out of which 16 presented chromosome 7 polysomy and 6 EGFR amplifications). FISH positivity did not associate with EGFR expression (p=0.403). No mutation in the studied EGFR exons was observed. A polymorphism without clinical significance (p.Q787Q in exon 20) was found in 19/27 cases. cHER2 expression and FISH positivity were an independent risk factor for cancer-specific and overall survival, respectively.

CONCLUSIONS: Success of targeted therapies is highly linked to appropriate patients selection and our findings might indicate that EGFR has a key role in penile carcinogenesis, making PSCC patients potential candidates for EGFR-targeted therapies since both EGFR expression and chromosome 7 polysomy are associated with poor prognosis. A possible interaction between membranous EGFR and cytoplasmic HER2 could favor the use of tyrosine-kinase inhibitors instead of monoclonal antibodies.

Citation Format: Alice M. T. Silva-Amancio, Isabela W. Cunha, Gustavo C. Guimaraes, Fernando A. Soares. Epidermal growth factor receptors and penile carcinoma: The role of EGFR and HER2 expression as prognostic and predictive markers. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3327. doi:10.1158/1538-7445.AM2014-3327

Polybromo-1 (PBRM1), a SWI/SNF complex subunit is a prognostic marker in clear cell renal cell carcinoma

OBJECTIVE

To analyse the immunohistochemical and mRNA expression of SWI/SNF (SWItch/Sucrose NonFermentable) complex subunit polybromo-1 (PBRM1) in clear cell renal cell carcinoma (ccRCC) and its impact on clinical outcomes.

PATIENTS AND METHODS

In all, 213 consecutive patients treated surgically for renal cell carcinoma (RCC) between 1992 and 2009 were selected. A single pathologist reviewed all cases to effect a uniform reclassification and determined the most representative tumour areas for construction of a tissue microarray. In addition, mRNA expression of PBRM1 was analysed by reverse transcriptase-polymerase chain reaction.

RESULTS

Of the 112-immunostained ccRCC specimens, 34 (30.4%) were PBRM1-negative, and 78 (69.6%) were PBRM1-positive. The protein expression of PBRM1 was associated with tumour stage (P < 0.001), clinical stage (P < 0.001), pN stage (P = 0.035) and tumour size (P = 0.002). PBRM1 mRNA expression was associated with clinical stage (P = 0.023), perinephric fat invasion (P = 0.008) and lymphovascular invasion (P = 0.042). PBRM1 significantly influenced tumour recurrence and tumour-related death. Disease-specific survival rates for patients whose specimens showed positive- and negative-PBRM1 expression were 89.7% and 70.6%, respectively (P = 0.017). Recurrence-free survival rates in patients with positive- and negative-expression of PBRM1 were 87.3% and 66.7%, respectively (P = 0.048).

CONCLUSIONS

PBRM1-negative expression is a markedly poor prognosis event in ccRCC. We encourage PBRM1 study by other groups in order to validate our findings and confirm its possible role as a useful marker in the management of patients with ccRCC.

Abstract 1165: Evaluation of HPV infection in penile cancer and its association with p16 and MGMT protein expression levels and pathologic variables

INTRODUCTION: Penile carcinoma is an infrequent tumor. However, in developing countries it is a common disease and in specific regions it may represents the most frequent tumor among men. The most important prognostic clinical factor is the presence of lymph node metastasis, which is associated with significant reduced survival to the penile carcinoma patients. Nevertheless, until the present date it was not possible to establish clinical or molecular prognostic markers. Various factors are associated with increased risk for de development of this disease, such as poor hygienic habits, lack of circumcision and HPV infection. HPV DNA can be detected in 20% to 80% of penile squamous cell carcinomas (PSCC). However, the role of HPV on patients’ prognosis is still uncertain. METHODS: We evaluated the frequency of HPV infection in 189 PSCC samples. The presence or absence of HPV DNA was established using generic primers (GP5+/GP6+) specific for the L1 gene of several HPVs. Specimens positive for HPV DNA were genotyped by dot blot hybridization using radioactive probes. We also evaluated the expression levels of the proteins p16 and MGMT through immunohistochemistry. These two proteins show aberrant levels in a wide range of tumors. Protein expression was quantified using an automated image system (ScanScope XT - Aperio), which determined the percentage and intensity of positive cells. The quantification was used to determine if there was loss of expression or normal (positive) expression. RESULTS: HPV infection, characterized by detection of viral DNA on the samples, was observed in 19.6% (37) of the cases. Among the positive HPV samples, 51.3% were infected by HPV16, 21.6% by HPV18 and 2.7% by both HPV16 and 18 concomitantly. The presence of HPV infection was more frequent among tumors with thickness lower than 5mm, suggesting that PSCC with HPV are less aggressive. This finding is in agreement with some studies that showed better prognosis of tumors with HPV infection. The immunohistochemistry assays showed reduced p16 expression in 35.4% (63) and loss of MGMT in 90.1% (146) cases. None association was observed between HPV infection and p16 protein expression. It is well established that the presence of HPV is associated with p16 positive expression. One interesting observation was that MGMT positive expression was associated with positive viral infection. Until this moment, there is no study describing this association in PSCC neither in other tumor types. It was observed an association between p16 reduced levels and poor differentiated tumors, this pathologic variable is associated with bad prognosis. MGMT loss of expression was associated with the presence of lymph node metastasis, suggesting that expression status of this protein can be a molecular marker for PSCC.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1165. doi:1538-7445.AM2012-1165

Abstract 4807: P16 and MGMT hypermethylation status evaluation in squamous cell penile carcinomas by pyrosequencing

Penile carcinoma is an uncommon disease and the most frequent subtype is squamous cell carcinoma. This cancer represents less than 1% of all cases in developed countries. However, in some regions of developing countries it represents 20% of all male cancers. The main risk factors associated to this tumor are poor hygienic habits, low quality of life, HPV infections and high number of sexual partners. Very little is known about penile carcinoma, including its pathogenesis, etiology and molecular biology features. In this study, we evaluated the hypermethylation status of two genes that present high frequencies of methylation in various tumor types. P16 plays an important role in cell cycle control. It encodes the protein p16 that binds to CDK proteins and inhibits pRB phosphorilation, blocking cell cycle progression. MGMT encodes a DNA repair protein that removes alkyl groups from guanines. The protein mgmt is peculiar once it acts alone and not in complexes like other DNA repair proteins. Hypermethylation of these genes is already described in a large variety of tumors, leads to gene silencing and has an important role in tumoregenesis. Here, we determined the frequency of hypermethylation among penile carcinoma samples and the percentage of aberrant methylation for each sample. The samples were submitted to bisulfite conversion, amplification and sequencing employing the pyrosequencing methodology, which is a quantitative methodology allowing percentage determination of each CpG dinucleotide analyzed. The hypermethylation status and methylation levels were evaluated in 33 squamous cell penile carcinoma samples. We observed P16 hypermethylation in 9% of the samples and MGMT was methylated in 27%, with levels of methylation varying from 10.71% to 35.43% and 12.20% to 62.60%, respectively. The low frequency of samples showing P16 hypermethylation could be explained by the presence of HPV infection, which is described in approximately 70.00% to 80.00% of penile carcinomas. It is well known that in the presence of HPV there is no P16 DNA methylation, suggesting that the HPV E7 protein influences the Rb pathway in these samples. MGMT hypermethylation frequency is in accordance with what was described by other groups and that showed no association to clinical characters of the samples analysed. Little is known about the influence of DNA hypermethylation on penile carcinoma tumorigenesis but our results show that the epigenetic alteration of P16 and MGMT genes are not tumor markers for penile carcinoma. To our knowledge it is the first study describing the epigenetic status of penile carcinomas in the Brazilian population.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4807. doi:10.1158/1538-7445.AM2011-4807

Double-barreled wet colostomy is a safe option for simultaneous urinary and fecal diversion. Analysis of 56 procedures from a single institution

BACKGROUND AND OBJECTIVES

Wide pelvic tumors need urinary and fecal diversion. We set out to assess the efficacy of the double-barreled wet colostomy (DBWC) in patients undergoing simultaneous double diversion.

MATERIAL AND METHODS

We reviewed 56 consecutive patients submitted to surgery, divided into two groups: (1) total pelvic exenteration plus DBWC (n = 26); (2) DBWC without simultaneous pelvic resection (n = 30). Pelvic tumor recurrences accounted for most patients (n = 53), whereas the remaining three patients suffered from actinic pelvic complications.

RESULTS

Surgical morbidity and mortality rates were 53.8% (14/26) and 11.5% (3/26) in Group 1, and 43.5% (13/30) and 3.3% (1/30) in Group 2, respectively. Only 2 patients out of 51 (3.9%) developed late postoperative urinary tract infection. Regression of the hydronephrosis was observed in 28 out of 33 assessable patients. Median survival in Groups 1 and 2 was 8.36 and 4.14 months, respectively. In the subgroup of patients submitted to curative surgery (n = 24), actuarial cancer-specific survival rate in 2 years was 58.78%.

CONCLUSION

DBWC is a safe and efficient alternative for simultaneous urinary and fecal diversion, with low morbidity and mortality rates, improvement of renal insufficiency, and low risk of postoperative urinary tract infection.