Renal Function: Implications on the Surgical Treatment of RCC

The good oncologic results after partial nephrectomy for stage 1 RCC show that radical nephrectomy is an overtreatment in most cases, and that many healthy nephrons are removed unnecessarily. However, partial nephrectomy is a difficult operation, with increased blood loss and a higher risk of complications. Therefore, the advantage of preserved function has to be weighed up against the increased trauma of surgery in each individual patient, and the assessment of preoperative function may influence this decision, among other factors such as comorbidities and age. In most studies, renal function has been assessed by means of estimated glomerular filtration rate, and this parameter is very helpful for long-term studies in large populations. However, more precise measurement based on clearance studies are sometimes required for more sophisticated investigations. The technique of partial nephrectomy has evolved substantially in recent years, resulting in the preservation of more nephrons, less damage to the remaining parenchyma, less blood loss, and a decreased risk of complications. The introduction of minimally invasive surgery for this purpose has also decreased the overall morbidity of surgery. In the long-term, chronic kidney disease may result in increased cardiac mortality. There is ongoing discussion on this problem, however, this potential negative influence on overall survival is not only influenced by the rate of renal insufficiency, but also to a great extent by other comorbidities such as hypertension and diabetes. Therefore, in addition to providing the best surgery for any given patient, we have to make sure that the treatment of the comorbidities will also be part of our patient management, since the risk of cardiac failure may be greater than the risk of poor oncologic outcome.

Early sacral neuromodulation ameliorates urinary bladder function and structure in complete spinal cord injury minipigs

Aims

To determine the effects of early sacral neuromodulation (SNM) and pudendal neuromodulation (PNM) on lower urinary tract (LUT) function, minipigs with complete spinal cord injury (cSCI) were analyzed. SNM and PNM have been proposed as therapeutic approaches to improve bladder function, for example after cSCI. However, further evidence on efficacy is required before these methods can become clinical practice.

Methods

Eleven adults, female Göttingen minipigs with cSCI at vertebral level T11‐T12 were included: SNM (n = 4), PNM (n = 4), and SCI control (SCIC: n = 3). Tissue from six healthy minipigs was used for structural comparisons. Stimulation was started 1 week after cSCI. Awake urodynamics was performed on a weekly basis. After 16 weeks follow‐up, samples from the urinary bladder were taken for analyses.

Results

SNM improved bladder function with better capacities and lower detrusor pressures at voiding and avoided the emergence of detrusor sphincter dyssynergia (DSD). PNM and untreated SCI minipigs had less favorable outcomes with either DSD or constant urinary retention. Structural results revealed SCI‐typical fibrotic alterations in all cSCI minipigs. However, SNM showed a better‐balanced distribution of smooth muscle to connective tissue with a trend towards the reduced progression of bladder wall scarring.

Conclusion

Early SNM led to an avoidance of the emergence of DSD showing a more physiological bladder function during a 4 month follow‐up period after cSCI. This study might pave the way for the clinical continuation of early SNM for the treatment of neurogenic LUT dysfunction after SCI.

Non-ischemic laparoscopic partial nephrectomy using 1318-nm diode laser for small exophytic renal tumors

Purpose

Warm ischemia (WI) and bleeding constitute the main challenges for surgeons during laparoscopic partial nephrectomy (LPN). Current literature on the use of lasers for cutting and coagulation remains scarce and with small cohorts. We present the largest case series to date of non-ischemic LPN using a diode laser for small exophytic renal tumors.

Methods

We retrospectively evaluated 29 patients with clinically localized exophytic renal tumors who underwent non-ischemic laser–assisted LPN with a 1318-nm wavelength diode laser. We started applying the laser 5 mm beyond the visible tumor margin, 5 mm away from the tissue in a non-contact fashion for coagulation and in direct contact with the parenchymal tissue for cutting. 

Results

The renal vessels were not clamped, resulting in a WIT (warm ischaemic time) of 0 min, except for one case that required warm ischemia for 12 min and parenchymal sutures. No transfusion was needed, with a mean Hemoglobin drop of 1,4 mg/dl and no postoperative complications. The eGFR did not significantly change by 6 months. Histologically, the majority of lesions (n = 22/29) were renal-cell carcinoma stage pT1a. The majority of malignant lesions (n = 13/22) had a negative margin. However, margin interpretation was difficult in 9 cases due to charring of the tumor base. A mean follow-up of 1.8 years revealed no tumor recurrence. The mean tumor diameter was 19.4 mm.

Conclusion

The 1318-nm diode laser has the advantages of excellent cutting and sealing properties when applied to small vessels in the renal parenchyma, reducing the need for parenchymal sutures. However, excessive smoke, charring of the surgical margin, and inability to seal large blood vessels are encountered with this technique.

Minimally Invasive Retroperitoneal Lymphadenectomy

The feasibility of laparoscopic retroperitoneal lymphadenectomy (RLA) for testicular cancer was shown >25 years ago. Initially the indication was clinical stage I (CS I) nonseminomatous germ cell tumor (NSGCT). Compared with that of open surgery, the morbidity was much decreased. However, in Europe, surgery for CS I is now replaced by chemotherapy. A relatively new indication is laparoscopic retroperitonal lymphadenectomy for small unilateral residual tumor after chemotherapy. The technique of unilateral lymphadenectomy for both indications is described in detail and with a video. The most recent development is bilateral laparoscopic RLA for residual tumors larger than 5 cm.

A new technique for minimal invasive complete spinal cord injury in minipigs

BACKGROUND

The aim of this study was to develop a minimal invasive complete spinal cord injury (SCI) minipig model for future research applications. The minipig is considered a translationally relevant model for SCI research. However, a standardized minimal invasive complete SCI model for pigs has not yet been established.

METHODS

Adult Göttingen minipigs were anesthetized and placed in extended prone position. After initial computed tomography (CT) scan, the skin was incised, a needle placed in the epidural fatty tissue. Using the Seldinger technique, a guidewire and dilators were introduced to insert the balloon catheter to Th12. After confirmation of the level Th11/Th12, the balloon was inflated to 2 atm for 30 min. The severity of the lesion was followed by CT and by MRI, and by immunohistochemistry. Function was assessed at the motor and sensory level.

RESULTS

Duration of procedure was about 60 min including the 30-min compression time. The balloon pressure of 2 atm was maintained without losses. The lesion site was clearly discernible and no intradural bleeding was observed by CT. Neurological assessments during the 4-month follow-up time showed consistent, predictable, and stable neurological deficits. Magnetic resonance imaging analyses at 6 h and 4 weeks post SCI with final immunohistochemical analyses of spinal cord tissue underlined the neurological outcomes and proved SCI completeness.

CONCLUSIONS

We have established a new, minimal invasive, highly standardized, CT-guided spinal cord injury procedure for minipigs. All risks of the open surgery can be excluded using this technique. This CT-guided SC compression is an excellent technique as it avoids long surgery and extensive trauma and allows a feasible inter-animal comparison.

The AR/NCOA1 axis regulates prostate cancer migration by involvement of PRKD1

Due to the urgent need for new prostate cancer (PCa) therapies, the role of androgen receptor (AR)-interacting proteins should be investigated. In this study we aimed to address whether the AR coactivator nuclear receptor coactivator 1 (NCOA1) is involved in PCa progression. Therefore, we tested the effect of long-term NCOA1 knockdown on processes relevant to metastasis formation. [(3)H]-thymidine incorporation assays revealed a reduced proliferation rate in AR-positive MDA PCa 2b and LNCaP cells upon knockdown of NCOA1, whereas AR-negative PC3 cells were not affected. Furthermore, Boyden chamber assays showed a strong decrease in migration and invasion upon NCOA1 knockdown, independently of the cell line's AR status. In order to understand the mechanistic reasons for these changes, transcriptome analysis using cDNA microarrays was performed. Protein kinase D1 (PRKD1) was found to be prominently up-regulated by NCOA1 knockdown in MDA PCa 2b, but not in PC3 cells. Inhibition of PRKD1 reverted the reduced migratory potential caused by NCOA1 knockdown. Furthermore, PRKD1 was negatively regulated by AR. Immunohistochemical staining of PCa patient samples revealed a strong increase in NCOA1 expression in primary tumors compared with normal prostate tissue, while no final conclusion could be drawn for PRKD1 expression in tumor specimens. Thus, our findings directly associate the AR/NCOA1 complex with PRKD1 regulation and cellular migration and support the concept of therapeutic inhibition of NCOA1 in PCa.

Laparoscopic Radical Cystectomy and Ileal Neobladder for Muscle Invasive Bladder Cancer in Combination with One Stage Prophylactic Laparoscopic Sacrospinal Fixation to Avoid Future Pelvic Organ Prolapse

Background: Women who undergo cystectomy with orthotopic ileal neobladder are more likely to have urinary retention and neocystocele mainly because of anatomical reasons than stress urinary incontinence. The risk is even higher in case of neurologic comorbidities, as in case of our patient.

Case Presentation: We present a laparoscopic mesh insertion for sacrospinal colposuspension to prevent a neocystocele and pelvic organ prolapse in combination with laparoscopic radical cystectomy in a female patient suffering from bladder cancer and chronic episodic multiple sclerosis. After a 30-month follow-up, the patient is continent and voids without residual urine. A dynamic MR of the pelvis shows a minimal rectocele without any evidence of a cystocele.

Conclusion: Laparoscopic cystectomy combined with sacrospinal mesh fixation is technically feasible and could be an option to prevent neocystocele for female patients.

Natural Orifice Transluminal Endoscopic Surgery-Assisted Laparoscopic Transvesical Bladder Diverticulectomy: Feasibility Study, Points of Technique, and Case Series with Medium-Term Follow-Up

OBJECTIVES

To demonstrate the feasibility of our novel natural orifice transluminal endoscopic surgery (NOTES)-assisted approach with medium-term follow-up.

PATIENTS AND METHODS

From March 2012, we included all patients who presented to our clinic with symptomatic or complicated retentive bladder diverticula secondary to long-standing infravesical obstruction. After managing the primary cause, we proceeded in all cases to our novel NOTES-assisted approach. We followed up the patients with abdominal ultrasonography at 6 weeks and 12 months postoperatively. Success was determined as subjective relief of the symptoms and objective disappearance of the diverticula in postoperative retrograde cystogram (RGC).

RESULTS

Between March 2012 and August 2014, eight diverticula were treated using our new technique. The surgery was uneventful. The mean operative time was 134.25 ± 44.92 minutes. Blood loss was minimal (>50 mL). Retrograde cystography was performed on the 10th postoperative day. The introduction of the needle holder through the urethral natural orifice (NOTES) facilitated a more optimal direction of the needle holder for suturing the bladder wall due to its parallel position in relation to the trigone and posterolateral walls. This renders this step easier compared with suturing the bladder wall through the transvesical laparoscopic ports. One case had a grade IIIa complication according to the Clavien-Dindo classification of surgical complications. The study is limited by the small number of cases.

CONCLUSION

Laparoscopic transvesical bladder diverticulectomy is a promising and safe procedure with good outcomes. Using the urethra (NOTES assisted) as an extra access to the bladder facilitates diverticular traction and bladder suturing without the need for extra ports. This technique can also be applied together with the novel T-laparoendoscopic single-site surgery approach.

[An incidental finding of retrocaval extraadrenal pheochromocytoma]

As part of diagnostic work-up of a 71-year-old patient with resistant hypertension, an extraadrenal mass was found. After further imaging and biochemical evaluation an extraadrenal pheochromocytoma was diagnosed and after alpha-receptor blockade was removed via posterior approach laparoscopically in the course. The pheochromocytoma is a rare catecholamine-producing tumor with an incidence of 1-2 per 100 000. In about 1-25 % it is located extraadrenal. Establishing the diagnosis is dependent on the demonstration of significant catecholamine excess. Afterwards imaging with CT or MRI should be performed. After administration of alpha-blockers, the complete surgical resection is the treatment of choice.

Fluorescence Guided Targeted Pelvic Lymph Node Dissection for Intermediate and High Risk Prostate Cancer

PURPOSE

We investigated whether visualization of the drainage system of the prostate by free indocyanine green would lead to identification of all or even more lymph node metastases detected by super-extended pelvic lymph node dissection in an intermediate and high risk patient population with prostate cancer.

MATERIALS AND METHODS

A total of 38 consecutive men with intermediate or high risk prostate cancer according to the D'Amico criteria underwent fluorescence targeted pelvic lymph node dissection during laparoscopic radical prostatectomy. Super-extended pelvic lymph node dissection was added as the control. Patients with neoadjuvant hormonal therapy, macroscopic lymph node involvement or prior transurethral prostate resection were excluded from study. Statistical descriptive methods, and the chi-square test and independent t-test were used to analyze data.

RESULTS

Mean patient age was 64.9 years (range 46 to 74) and mean preoperative prostate specific antigen was 13.8 ng/ml (range 0.3 to 44). A total of 23 (60.5%) and 15 cases (39.5%) were classified as intermediate and high risk, respectively. Fluorescence stained nodes were found on each side in all except 1 patient. A total of 700 lymph nodes (mean ± SD 18.4 ± 8.2 per patient) were removed, of which 531 (75% of all nodes) were fluorescence stained (mean 14 ± 8.07 per patient). Lymph node metastases were found in 15 patients (39.5%). Two patients (5.3%) had a solitary micrometastasis and 3 (7.9%) had nodes containing isolated tumor cells. Metastases were found outside the extended pelvic lymph node dissection template in 5 of 15 patients (33.3%). Three of those 5 patients attained a prostate specific antigen nadir of less than 0.1 ng/ml 6 weeks postoperatively. Fluorescence targeted pelvic lymph node dissection showed superior sensitivity and negative predictive value compared to extended and super-extended pelvic lymph node dissection to detect lymph node metastasis.

CONCLUSIONS

Fluorescence targeted pelvic lymph node dissection allows for the lymphatic drainage of the prostate to be identified with great reliability. Since only the nodes draining the prostate are removed, the absolute number of removed nodes is decreased while diagnostic accuracy is increased.

Evidence from the 'PROspective MulticEnTer RadIcal Cystectomy Series 2011 (PROMETRICS 2011)' study: how are preoperative patient characteristics associated with urinary diversion type after radical cystectomy for bladder cancer?

PURPOSE

The aim of this study was to examine preoperative patients' characteristics associated with the urinary diversion (UD) type (continent vs. incontinent) after radical cystectomy (RC) and UD-associated postoperative complications.

MATERIALS

In 2011, 679 bladder cancer patients underwent RC at 18 European tertiary care centers. Data were prospectively collected within the 'PROspective MulticEnTer RadIcal Cystectomy Series 2011' (PROMETRICS 2011). Logistic regression models assessed the impact of preoperative characteristics on UD type and evaluated diversion-related complication rates.

RESULTS

Of 570 eligible patients, 28.8, 2.6, 59.3, and 9.3% received orthotopic neobladders, continent cutaneous pouches, ileal conduits, and ureterocutaneostomies, respectively. In multivariable analyses, female sex (odds ratio [OR] 3.9; p = 0.002), American Society of Anesthesiologists score ≥3 (OR 2.3; p = 0.02), an age-adjusted Charlson Comorbidity Index ≥3 (OR 4.1; p < 0.001), and a positive biopsy of the prostatic urethra in the last transurethral resection of the bladder prior to RC (OR 4.9; p = 0.03) were independently associated with incontinent UD. There were no significant differences in 30- and/or 90-day complication rates between the UD types. Perioperative transfusion rates and 90-day mortality were significantly associated with incontinent UD (p < 0.001, respectively). Limitations included the small sample size and a certain level of heterogeneity in the application of clinical pathways between the different participating centers.

CONCLUSIONS

Within this prospective contemporary cohort of European RC patients treated at tertiary care centers, the majority of patients received an incontinent UD. Female sex and pre-existing comorbidities were associated with receiving an incontinent UD. The risk of overall complications did not vary according to UD type.

Laparoscopic placement of a tined lead electrode on the pudendal nerve with urodynamic monitoring of bladder function during electrical stimulation: an acute experimental study in healthy female pigs

Purpose

The aim of this study was to develop a method for standard laparoscopic access to the pudendal nerve in pigs to implant an electrode for chronic neuromodulation studies.

Methods

Using routine laparoscopic surgical techniques, the pudendal nerve was located in 10 female pigs using standardized anatomical landmarks. A tined lead electrode was placed in parallel to the exposed pudendal nerve, and acute unilateral electrical stimulation was performed consecutively on both pudendal nerves. Bladder pressure and perineal skeletal muscle response was monitored during stimulation.

Results

Standard access to the pudendal nerve was successfully established in the pig model with surgical times of approximately 45 minutes for bilateral electrode placement. Acute unilateral stimulation did not evoke bladder responses but resulted in reliable stimulation-dependent activity of the perineal skeletal muscles. The structural integrity of the pudendal nerves was confirmed in all cases.

Conclusions

These results illustrate the effectiveness of laparoscopy for standardised, safe nerve localisation and electrode implantation at the pudendal nerve in pigs. Laparoscopic implantation represents an alternative approach for performing electrode implantation under optical guidance versus the standard approach of percutaneous, neuro-physiological monitored implantation. In the future, pudendal neuromodulation may be used as a supplement to sacral neuromodulation or as a standalone therapeutic approach, depending on the underlying bladder dysfunction.

Update on the use of diode laser in the management of benign prostate obstruction in 2014

AIM

To determine the status quo in respect of various diode lasers and present the techniques in use, their results and complications. We assess how these compare with transurethral resection of the prostate and other types of laser in randomized controlled trials (RCTs). When adequate RCTs were not available, case studies and reports were evaluated.

MATERIALS AND METHODS

Laser for the treatment of benign prostatic hyperplasia (BPH) has aroused the interest and curiosity of urologists as well as patients. The patient associates the term laser with a successful and modern procedure. The journey that started with coagulative necrosis of prostatic adenoma based on neodymium: yttrium-aluminum-garnet (Nd:YAG) laser has culminated in endoscopic "enucleation" with holmium laser. Diode laser is being used in urology for about 10 years now. Various techniques have been employed to relieve bladder outlet obstruction due to BPH.

RESULTS

The diode laser scenario is marked by a diversity of surgical techniques and wavelengths. We summarize the current published literature in respect of functional results and complications.

CONCLUSION

More randomized controlled studies are needed to determine the position and the ideal technique of diode laser treatment for BPH.

Tissue effects resulting from eraser laser enucleation of the prostate: in vivo investigation

BACKGROUND/AIMS/OBJECTIVES: To describe the depth of the laser coagulation zone in vivo based on histological examinations and the functional outcome of a 1,318-nm diode laser for enucleation in benign prostatic enlargement (BPE).

METHODS

A total of 20 patients with BPE were treated by laser Eraser® enucleation of the prostate (ELEP). Prostatic tissue wedges were evaluated to assess the depth of the ELEP coagulation zones. Additionally, patients were assessed preoperatively and 12 months postoperatively.

RESULTS

The coagulation zones were 0.36 ± 0.17 mm in epithelial tissue, 0.28 ± 0.15 mm in stromal tissue, and 0.25 ± 0.12 mm in mixed tissue. The coagulation area at the cutting edge completely sealed capillary vessels, reaching a depth of 0.35 ± 0.15 mm. The diameter of the coagulated vessels measured 1.75 ± 0.83 mm. Mean blood loss was 115.54 ± 93.12 ml, catheter time 1.35 ± 0.33 days, and hospital stay 1.89 ± 0.52 days. The International Prostate Symptom Score, maximal flow rate, and quality of life significantly improved 12 months after the procedure.

CONCLUSIONS

ELEP is safe and effective for BPE treatment and yields good results at a follow-up of 1 year. Because of the limited penetration depth, damage to the urinary sphincter is not expected.

A severe complication of mid-urethral tapes solved by laparoscopic tape removal and ureterocutaneostomy

Mid-urethral tapes are largely used to manage stress urinary incontinence (SUI). In certain cases, however, this procedure results in bothersome complications that lead to complete resection. We present the case of an 85-year-old woman who presented with ongoing suprapubic pain, hematuria, vaginal bleeding and recurrent urinary tract infections. The patient had undergone a tension-free vaginal tape (TVT) procedure in 1999 and a transobturator tape (TOT) placement in 2003 for SUI. Investigations revealed a urethral stone, erosion of both TOT and TVT and an urethra-vaginal fistula. Under local anesthesia the urethral stone was removed endoscopically and the TOT removed via a vaginal approach. Due to her comorbidity, she underwent a laparoscopic intraperitoneal removal of the TVT and a definitive ureterocutaneostomy to relieve her pain, inflammation and incontinence. This is the first ever presented case of erosion of mid-urethral tapes and incontinence treated with a laparoscopic resection of the tape and ureterocutaneostomy as definitive urinary diversion.

Cooling mechanisms in laparoscopic partial nephrectomy: are really necessary?

OBJECTIVE

The purpose of this review is to provide an overview of the possibilities and drawbacks of the various possibilities of renal parenchymal cooling during laparoscopic partial nephrectomy and also give an outlook into future developments.

METHODS

In January 2012 a PubMed Search using the search terms "partial nephrectomy, cooling," followed by a systematic and critical review was performed.

CONCLUSION

Renal cooling during laparoscopic partial nephrectomy is a feasible, safe and effective procedure to expand ischemia time up to over 60 minutes, without risking significant and long lasting deterioration of renal function. It can be of value in patients with an imperative indication for partial nephrectomy, like solitary kidneys, synchronous bilateral tumors or renal failure in the opposite kidney as well as for patients at risk for deterioration of renal function and in any situation, where you think to yourself that 20 minutes will be maybe not enough to finish the job technically. Renal arterial perfusion provides the clinically best-studied option in this situation followed by ice-cold saline irrigation. Other surface coolants look promising, but still lack clinical data.

Laparoscopic treatment of intrinsic endometriosis of the urinary tract and proposal of a treatment scheme for ureteral endometriosis

OBJECTIVE

To discuss the contemporary management of urinary tract endometriosis and report our experience concerning laparoscopic treatment of intrinsic urinary tract endometriosis.

METHODS

We performed a retrospective, multicenter study of data collected from March 2006 to March 2011. Ten women were referred from gynecology, seven with ureteral involvement and hydronephrosis and three with bladder involvement, for urologic management. Of the 7 women with hydronephrosis, 5 were symptomatic, with recurrent urinary tract infections or pain. All 3 women with bladder endometriosis had hematuria. All patients had previously undergone unsuccessful hormonal therapy. Ureteral endometriosis was extensively investigated and treated by laparoscopic excision of endometriotic plaques and excision of intrinsic endometriosis of the ureter. Bladder endometriosis was treated by partial cystectomy. Some patients also had endometriosis in other organs and underwent, for example, wedge resection of sigmoid colon and oophorectomy.

RESULTS

The median age of the patients was 30 years (range 25-44). Seven patients with intrinsic endometriosis of the ureter all had hydronephrosis and proximal hydroureter and underwent laparoscopic ureteral segment excision and either end-to-end, spatulated uretroureterostomy or ureteral reimplatation with psoas hitch. Three patients had hematuria, and cystoscopic biopsy of the bladder lesions confirmed intrinsic endometriosis. They were treated with laparoscopic partial cystectomy. One patient with bowel symptoms also underwent laparoscopic wedge resection of the sigmoid colon and another underwent oophorectomy for a chocolate cyst. Most patients also had peritoneal endometriotic plaques excised. We did not perform simple ureterolysis. No complications were encountered. The median follow-up was 26.5 months (range 4-53), with no return of symptoms or recurrence. The annual follow-up examinations included urinalysis and ultrasonography of the urinary tract.

CONCLUSION

Intrinsic endometriosis can be successfully managed with minimally invasive techniques to provide relief of symptoms, protect renal function, and prevent recurrence. We describe a classification of ureteral endometriosis determined from staging investigations.

[Partial nephrectomy - pro laparoscopy]

Partial nephrectomy has become the most frequently used surgical procedure in the treatment of renal cell cancer. The current role of laparoscopy for this indication has to be defined.The technique of laparoscopic partial nephrectomy has undergone a continuous development to become mature. Once the learning curve of the individual surgeon has been overcome the results are comparable to those of open surgery. This is true for ischemia time, complication rate and oncologic outcome. In addition there is the advantage of the minimally invasive approach in laparoscopy sparing a painful flank incision. Laparoscopic partial nephrectomy is not yet a standard of care but yields excellent results in the hands of experts. There are no conclusive studies comparing standard and da Vinci®-assisted laparoscopy. No clear advantages become obvious, but the costs of the robot are substantial.

[Retroperitoneal lymphadenectomy - pro laparoscopy]

The functional and oncological results of laparoscopic retroperitoneal lymphadenectomy (L-RPLND) have proven to be as efficacious as open series (O-RPLND) after 5 year follow-up. In the most recent publication series from high-volume laparoscopy centres, there was a trend towards fewer complications in L-RPLND compared to O-RPLND. Up to now only two case series of four treated patients have been reported adopting a robotic-assisted retroperitoneal lymphadenectomy for testicular cancer so that it is not yet possible to judge whether it is useful tool or not.

Fluorocholine (18F) and sodium fluoride (18F) PET/CT in the detection of prostate cancer: prospective comparison of diagnostic performance determined by masked reading

AIM

The aim of this paper was to compare the diagnostic performance of positron emission tomography/computed tomography (PET/CT) with fluorocholine (18F) (FCH) or fluoride(18F) (FNa) for the detection of bone metastasis in patients with prostate cancer complaining from osteoarticular pain, taking into account whether they were referred for initial staging or recurrence localization. The initial hypothesis was that FCH site-based specificity would be superior to that of F Na, with no loss in sensitivity.

METHODS

Forty-two patients were enrolled in this prospective study, underwent both PET/CTs and were then followed-up for at least 6 months. The standard of truth (SOT) about the presence/absence and location of bone metastasis could be determined in 40 patients, by 2 independent medical assessors, blinded to the results of both PET/CTs. The comparison was performed according to the guideline of the European Medicines Agency, i.e. based on the results of blind reading with SOT as reference.

RESULTS

Bone extension was present in 22 patients and absent in 18. Patient-based performance for FCH vs. FNa was 91% vs. 91% for sensitivity, 89% vs. 83% for specificity and 90% vs. 88% for accuracy (no significant difference). Of 360 skeletal sites, 68 were malignant and 292 non-invaded. There was no significant difference in site-based performance in the group of patients referred at initial staging, but in the group of patients referred for suspicion of recurrence, FCH was significantly more specific than FNa (96% vs. 91%, P=0.033 with Obuchowski's correction) while sensitivity was the same, 89%.

CONCLUSION

Both radiopharmaceuticals, based on a very different metabolic approach, showed good diagnostic performance. If FCH is available, it should be preferred in patients after initial treatment.

Delayed detection of injury to an ectopic ureter of a duplicated collecting system following laparoscopic radical prostatectomy for early organ-confined prostate cancer

In the era of early detection of organ-confined prostate cancer, guidelines support the fact that many patients will not need an aggressive staging work-up, to avoid unnecessary investigations. This strategy may lead to serious repercussions in rare incidences. We present a rare case of urinary extravasation following laparoscopic radical prostatectomy caused by injury of the upper pole ectopic ureter of an undetected duplex system on 1 side, an injury which is the first of its kind in laparoscopic urology.

Practical hints for hemostasis in laparoscopic surgery

With the developments achieved in recent years in laparoscopic surgery, the field has acquired a host of new techniques to achieve haemostasis, allowing the surgeon to tackle complex procedures. These techniques include physical modalities (as simple as compression or suturing and as sophisticated as endovascular staples), thermal modalities (such as bipolar coagulation, laser or ultrasonic dissectors), and topical sealants (e.g. Fibrin glue or gelatine matrix). It is up to the laparoscopic surgeon to be familiar with all these different modalities and their proper use and limitations. It should also be kept in mind that the best approach to haemostasis in laparoscopy is prevention by thorough case preparation and meticulous dissection technique. We herein expose an overview of the available techniques to achieve haemostatic control in laparoscopic surgery in the emergency as well as the elective setting. Representative surgeries are used for illustrative purposes to describe special manoeuvres.

Laparoscopic partial adrenalectomy

The concept of organ- and function-preserving surgery without compromising the primary goal of complete tumour removal has been recently applied in adrenal surgery. This has been accomplished by open surgery in the past. With recent advancements in minimally invasive surgery, partial adrenalectomy by laparoscopic approach has become feasible. The indications, contraindications and worldwide experience have been reviewed for this article.

Extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome in males: a randomised, double-blind, placebo-controlled study

BACKGROUND

There is no sufficiently validated therapy for chronic pelvic pain syndrome (CPPS).

OBJECTIVE

To investigate the effects of extracorporeal shock wave therapy (ESWT) in 60 patients suffering from CPPS.

DESIGN, SETTING, AND PARTICIPANTS

Sixty patients suffering from CPPS for at least 3 mo were investigated in two groups. Both groups were treated four times (once per week), each by 3000 impulses; group 2 was performed as a sham procedure. The investigation was designed as a placebo-controlled, prospectively randomised, double-blind phase 2 study. Standardised follow-up was performed 1, 4, and 12 wk after ESWT.

INTERVENTIONS

Low-energy-density ESWT was performed using a perineal approach without anaesthesia. In the placebo group, the same setting was used without shock wave energy transmission.

MEASUREMENTS

ESWT effects on pain, quality of life (QoL), erectile function (EF), and micturition were evaluated. The parameters were investigated using validated questionnaires (National Institutes of Health Chronic Prostatitis Symptom Index [NIH-CPSI], International Prostate Symptom Score [IPSS], International Index of Erectile Function [IIEF]) and the Visual Analog Scale (VAS) for pain evaluation.

RESULTS AND LIMITATIONS

All patients completed outpatient treatments and follow-ups without any problems. All 30 patients in the verum group showed statistically (highly) significant improvement of pain, QoL, and voiding conditions following ESWT in comparison to the placebo group, which experienced a continuous deterioration of the same parameters during the follow-up period. Perineal ESWT was easy and safe to perform without anaesthesia or any side-effects.

CONCLUSIONS

This is the first prospectively randomised, double-blind study to reveal perineal ESWT as a therapy option for CPPS with statistically significant effects in comparison to placebo. ESWT may in particular be interesting because of its easy and inexpensive application, the lack of any side-effects, and the potential for repetition of the treatment at any time.

Varicocele

INTRODUCTION

Varicocele is estimated to affect 10-15% of men and adolescent boys. It usually occurs only on the left side, and is often asymptomatic. There is little evidence that varicocele reduces male fertility, although it is found in 12% of male partners of couples presenting with infertility, and in 25% of men with abnormal semen analysis.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments in men with varicocele? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 11 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: embolisation, expectant management, sclerotherapy, and surgical ligation.

Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective

CONTEXT

Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is not recommended as standard tool in European Association of Urology (EAU) guidelines.

OBJECTIVE

To update the role of L-RPLND in patients with clinical stage I nonseminomatous germ cell tumour (NSGCT) compared to open retroperitoneal lymph node dissection (O-RPLND).

EVIDENCE ACQUISITION

A systematic literature search from 1992 to 2008 was performed in Medline, EMBASE, and Cochrane. The largest series from each group was considered. Comparative analysis was based on raw data of series published in 2000 and later.

EVIDENCE SYNTHESIS

Results of >800 patients treated by L-RPLND reported in 34 articles were analyzed. Lymph node dissection (LND) was based on modified templates, removing an average of 16 (5-36) lymph nodes. At experienced centres, complication rates were 15.6% (9.4-25.7), including 2% (0-5) retrograde ejaculation and 1.7% (0-6) reintervention. Operating room times are longer compared to O-RPLND (204 vs 186min). Five publications with a follow-up of 63 (36-89) mo include 557 patients. One hundred twenty-six of 140 (90%) patients with positive nodes (25%, range: 17-38) received adjuvant chemotherapy, resulting in a local relapse rate of 1.4% (0.7-2.3) with no in-field recurrence; rate of distant relapses was 3.3% (1.8-4.6), including one port-site metastasis; and rate of biochemical failure was 0.9% (0.7-2.3). Two of 14 patients with positive nodes (pN1) who did not receive adjuvant chemotherapy relapsed, both 8 mo after surgery, and were salvaged by chemotherapy. Compared with O-RPLND, there was no difference in relapse rates, percentage of patients receiving chemotherapy (29% vs 31%), chemotherapy (CTx) cycles per cohort (0.6), rate of salvage surgery (1.2% vs 1.5%), and patients with no evidence of disease (NED; 100% vs 99.7%).

CONCLUSIONS

L-RPLND offers similar staging accuracy and long-term outcome to O-RPLND. In a late series of experienced L-RPLND centres, there was a trend towards fewer complications. L-RPLND represents a valuable tool for experienced laparoscopic surgeons. Further studies must focus on the curative potential of the procedure in pathologic stage IIA.