Kernspintomographisches Staging des Prostatakarzinoms mittels kombinierter Endorektal-Body-Phased-Array-Spule und histopathologische Korrelation

PURPOSE

Evaluation of the diagnostic value of the combined endorectal body-phased array technique regarding the staging of prostate cancers, especially in the differentiation between stages T2 and T3.

MATERIALS AND METHODS

Forty-two patients with biopsy-proven or clinically suspected prostate cancer were examined on a 1.5 T scanner (Siemens, Symphony) prior to radical prostatectomy. T (2)-weighted TSE (axial, coronal) and T (2)-weighted FSE (axial) sequences were obtained with and without fat suppression. After application of 0.2 mmol/kg body-weight Gd-DTPA, T (1)-weighted GRE sequences were obtained using dynamic MRI. All images were prospectively interpreted by two observers. The MR images were correlated with the histopathological findings of wide-area sections of prostatectomy specimens.

RESULTS

For the detection of extracapsular growth and seminal vesicle infiltration (T2 versus T3) the accuracy was between 94 % and 97 % (sensitivity 100 %, specificity between 87 % and 93 %, observer 1 and 2). In two cases with a histologically proven stadium pT2b, observer 1 had diagnosed stadium pT3a. The results of observer 2 were marginally better in only one case, which was histologically proven to be pT2b and overstaged as pT3a. MRI did not lead to under-staging of a single tumor with regard to the differentiation between T2 and T3. Overall, the staging of the tumor stages (T1 - T4) was correct in 25 of 33 cases (75 %). The dynamic MRI showed no improvement regarding sensitivity (100 %) and specificity (62 %) and achieved a staging accuracy of only 75 %.

CONCLUSION

MRI performed with a combination of a pelvic phased-array coil (PPA) and integrated endorectal coil plays a significant role in the preoperative staging of prostate cancer. However, differentiation between capsular infiltration (T2) and penetration (T3) as well as evaluation of the seminal bladder (T3b) seem to be difficult.

First report on sequential totally endoscopic thymomectomy and adrenalectomy using computer-enhanced telemanipulation

BACKGROUND

Laparoscopic adrenalectomy is considered the standard method for removal of benign adrenal tumors, regardless of hormone activity. Minimally invasive surgery for thymomectomy aims at limited approaches, avoiding complete sternotomy or large thoracotomy.

METHODS

We report on a case in which totally endoscopic thymomectomy and adrenal gland resection were performed sequentially using a computer-enhanced telemanipulation system within 3 weeks.

RESULTS

Operating time was 4.5 h for totally endoscopic adrenalectomy and 1.5 h for totally endoscopic thymomectomy. The patient was transferred to the normal ward on the day of operation after either procedure and had an uneventful recovery. Pathology yielded no malignancy in both cases.

CONCLUSION

This report demonstrates the safety and feasibility of various totally endoscopic procedures performed sequentially.

Robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic ileal neobladder

PURPOSE

To describe our technique of robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic neobladder (Hautmann) for treatment of transitional cell carcinoma of the bladder.

METHODS

We describe our surgical technique in the worldwide first attempt to perform a robotic-assisted laparoscopic radical cystectomy and completely intra-abdominal formation of an orthotopic neobladder. The DaVinci System (Intuitive Surgical, Mountain View, CA, USA) was utilized to perform the procedure.

RESULTS

Utilizing the DaVinci System the operation could be performed without any complications. Operating time was 8.5 hours, blood loss was 200 ml. The oncologic as well as the functional result of the reservoir were excellent.

DISCUSSION

We here demonstrated that sophisticated laparoscopic procedures like the intra-abdominal formation of an orthotopic neobladder are accomplishable with robotic assistance.

Robotic-assisted laparoscopic radical prostatectomy: the Frankfurt technique

The robotic technique, which was first introduced in laparoscopic heart surgery, has revolutionized laparoscopic surgery over the last 5 years. In May 2000, our department accomplished the first robot assisted laparoscopic radical prostatectomy. Since that time we have performed more than 118 such procedures and several other laparoscopic operations using the robotic technique. We here summarize our experience in robot assisted laparoscopic radical prostatectomy as it has been developed over the past 3 years. Between May 2000 and May 2003, 118 patients with clinically localized prostate cancer were operated using the telerobotic da Vinci Surgical System. Operations were performed with a senior surgeon at the console, assisted by an assistant and a nurse at the operating table. Bilateral pelvic lymph node dissection was undertaken as a first step in all patients. In the initial 60 cases, we investigated different laparoscopic approaches. We used transperitoneal as well as extraperitoneal approaches. For dissection of the prostate we used ascending, descending as well as combined techniques. The combined ascending and descending technique via the transperitoneal route was chosen in 30 patients, and via the extraperitoneal route in seven patients. A modification of the descending Montsouris technique was performed in 81 patients. The robot assisted laparoscopic radical prostatectomy with the da Vinci system has been well standardized. After performing more than 100 radical prostatectomies with this system, we conclude that in our hands the Montsouris technique with only minor adoptions is the most appropriate technique for performing robot assisted radical prostatectomy.

A yeast bioassay for trichothecenes

Like all eucaryotic cells, yeasts are sensitive to trichothecenes, especially T-2 toxin and verrucarin A. Based on this sensitivity, a yeast bioassay was developed to evaluate the toxicity of corn samples. The bioassay was optimized using spiked maize extracts. The toxicity of samples was defined as toxicity equivalent to a certain concentration of T-2 toxin standards. The assay can be performed on crude extracts, but the results are more precise after column clean-up. The test can also be used for the screening of trichothecene toxicity in general. The relative standard deviation (RSD) at 85 % growth inhibition (EC85) was 4.5% for the T-2 toxin standards (n = 8). This corresponds to an initial T-2 toxin concentration of approximately 58 ppb in the corn sample. Samples containing 188 and 113 ppb T-2 toxin caused a growth inhibition higher than 85%, whereas samples with toxin concentrations of 56 and 19 ppb had a growth inhibition less than 85%. Therefore the test can be used for the qualitative evaluation of corn samples up to a level of 58 ppb +/- 2.8 ppb. The bioassay is easy to perform with minimum requirements for equipment. Results can be obtained within 24 h and a large number of samples can be analysed daily. The costs are low and the results obtained are repeatable. With some modifications this test can be used for toxicity studies on trichothecene metabolites as well as for extracts with unknown compounds with properties similar to trichothecenes.

[Robot-assisted laparoscopy in urology. Radical prostatectomy and reconstructive retroperitoneal interventions]

Complex reconstructive laparoscopic procedures in the field of urology such as radical prostatectomy and pyeloplasty have attracted increased attention in the past 2 years. However, extensive laparoscopic experience is required to master these procedures. Therefore, it remains questionable whether these techniques, which have been shown to be of profit to the patient in the hands of a specialist, will achieve widespread distribution. We have employed computer technology to bridge the gap between open surgery and laparoscopic access and used the daVinci Surgical System to establish laparoscopic radical prostatectomy as well as pyeloplasty and other retroperitoneal procedures at our institution. With experience of more than 70 procedures, we find that with the assistance of the daVinci Surgical System both radical prostatectomy and retroperiteoneal procedures can be easily translated from open to minimally invasive procedures with a considerably shorter learning curve and without compromising patient safety. We expect that large incisions will be soon a thing of the past in urologic surgery. Computer technology, together with mechanical engineering, will play a major role in enabling us to achieve better results despite minimal invasiveness.

Synchronous bladder augmentation and living related kidney transplantation

Ileocystoplasty for enlargement of bladder capacity in conjunction with renal transplantation has been described in several cases. However, the surgical approach has been accomplished as a two-stage procedure. We report the case of a 21-year-old female myelomeningocele patient with end-stage renal insufficiency who was treated with ileocytstoplasty and living related renal transplantation at a single stage. Convalescence remained uneventful. On follow-up 13 months after the operation, the renal parameters remained stable.

[The Frankfurt concept for health counseling for men]

The discussion on the difference between the sexes received significant impulses from the formation of feminist theory. Masculinity was interpreted in a rather morally negative manner. Masculinity continuously endeavors to achieve reproduction and self-confirmation. Competitive pursuit of hegemony is the preeminent pattern by which masculine identity is formed. Male socialization leads to externalization, which impedes the development of communicative skills. Males tend to lead a high-risk life-style, which instrumentalizes their body. Symptoms are less often interpreted as warning signals, reflected in a significantly reduced life expectancy in comparison to females. In view of the specific male socialization, the Frankfurt concept of "men's health counseling" attempts to create a professional atmosphere in which men seeking advice are offered the opportunity to consult a specialist on all topics of men's health anonymously and, for the moment, free of charge.

Development of a screening instrument for language in older people (Barnes Language Assessment)

Language changes are associated with several types of age-related degenerative processes and are known to be particularly stressful for carers. Managing language and communication difficulties in older people has been shown to be an important aspect of dementia care. A test such as the one described here, might be a useful tool for health professionals planning care for older people with possible diagnoses of dementia. The information gained could be used as part of multi-disciplinary team assessment. This paper describes the development of a clinically viable assessment tool for the assessment of language and associated cognitive skills in the older population. Data on 43 normal older people were used to establish preliminary means and lower normal limits, as a guide to distinguishing performance associated with normal age-related change from performance associated with pathology. In the next phase data was collected from 43 older people with possible dementia who were attending clinics and hospital departments. The results suggest that the Barnes Language Assessment can profile language skills and difficulties and may be a useful diagnostic tool to contribute to language assessment of older people. Indications for further research are discussed.

Robotic and telesurgery: will they change our future?

In urology, at the end of the last millennium, there was an increasing use of computerized technology, extracorporeal shock wave lithotripsy, microwave therapy and high-energy focused ultrasound. However, experience with manipulating robots in urological surgery is still very limited. Laparoscopic surgery is handicapped by a reduction of the range of motion because of the fixed trocar position. The da Vinci system is the first surgical system to address all these problems adequately. The system consists of two main components: the surgeon's viewing and control console with three-dimensional imaging and the surgical arm unit that positions and manoeuvres detachable surgical instruments. The surgeon performs the procedure seated at the console holding specially designed instruments. Telerobotic laparoscopic radical prostatectomy provides advantages such as stereovision, dexterity and tremor filtering, but there is a learning curve with the device, mainly because of the magnification, the three-dimensional image and the lack of tactile feedback. However, after only a short period of time, the experienced surgeon is able to become familiar with the device. The impact of robotics in urological surgery is therefore very promising, and we are convinced that it will totally change the future of urological surgery.

A screening instrument for language in older people (Barnes Language Assessment)

This paper describes the development of a clinically viable tool for the assessment of language and associated cognitive skills in the older population which was instigated by the SIG Psychiatry of Old Age (South of England). A series of sub-tests is described. Data from normal older people is used to establish preliminary means and lower normal limits as a guide to distinguishing performance associated with normal age-related change from performance associated with pathology. The importance of allowing for the effects of normal age-related changes on language processing is illustrated. Data from older people with pathology attending clinics and hospital departments is also presented. Quantitative and qualitative language profiling is outlined. Data analysis suggests that the Barnes Language Assessment is able to profile language skills and difficulties. Indications for further research are discussed.

[Neuropsychological deficits in the initial acute episode of schizophrenia. A comparison with chronic schizophrenic patients]

By administering an extensive battery of neuropsychological tests, cognitive performance of 66 patients with first episode schizophrenia, 49 patients with chronic schizophrenia and 40 healthy controls has been assessed in the areas of memory functions, speech and cognitive flexibility/abstraction. The three groups were comparable with regard to age, gender and education. Both patient groups showed a significant generalized neuropsychological impairment relative to controls. Patients with first episode were most impaired in visual motor processing and attention (VSM). Besides impairment in VSM, performance in abstraction/flexibility was significantly worse in chronic schizophrenics compared to first episode schizophrenics. Our findings suggest that neuropsychological functions are already impaired at the onset of the illness. Whether cognitive impairment in performance that is attributed to frontal dysfunctions is deteriorating during the course of the illness or is predicting an unfavourable course can only be answered by prospective follow-up studies.

Neuropsychological impairment and psychopathology in first-episode schizophrenic patients related to the early course of illness

The objective of the present study was to explore whether the early course of illness including first onset of psychotic symptoms influences neuropsychological functioning and psychopathology in first-episode schizophrenics. Patients with a short prodromal period (n = 20) and patients with a long prodromal period (n = 20) and controls matched with regard to age, gender and education (n = 40) were administered a battery of standardized neuropsychological tests and psychopathological rating scales. The results indicate an overall difference in neuropsychological performance with the schizophrenic patients scoring lower than controls. Schizophrenic patients scored significantly lower in all subtests except in visual memory and abstraction/flexibility than controls. No significant difference between neuropsychological performance between patient samples was found. Psychopathology was more pronounced in the long prodromal period group rating higher on negative and affective symptoms compared with the short prodromal period group. The data suggests that neuropsychological deficits in first-episode schizophrenia are independent of the early course of schizophrenia, and although negative symptoms are associated with the length of the prodromal period, they do not imply greater neuropsychological impairment.

Functional magnetic resonance imaging. Language mapping

This article discusses the use of functional magnetic resonance (fMR) imaging to localize language. Suggestions are made for ensuring visualization of language areas by selection of effective activation tasks. It is argued that the superior temporal gyrus responses evoked by listening to speech represent auditory, rather than language, processing. fMR imaging studies using word generation and semantic decision tasks are reviewed in detail. These data indicate that fMR imaging is capable of mapping language areas in the brain, although results have been variable. fMR imaging language results obtained using a semantic decision task correspond closely to language laterality measures determined with the Wada test.