Evaluation of the M371-Test Under Real-life Conditions for Diagnosis and Follow Up of Testicular Germ Cell Tumors

BACKGROUND/AIM

The aim of the study was to establish the performance of the M371-Test on the Thermocycler Rotor-GeneQ (Qiagen) platform for diagnosis and follow-up of testicular tumors and to evaluate the test under real-life conditions in comparison to the classical markers alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (β-HCG) and lactate dehydrogenase (LDH).

PATIENTS AND METHODS

Forty-four patients, of median age 29 years (range=24-84) were included in this prospective study at our institution between March 2021 and September 2022. Of the 44 patients, 23 had a suspicion of testicular cancer (TC) and 21 were under follow-up for TC. In total, 96 M371-Tests were performed and compared with AFP, β-HCG, LDH using histological diagnosis and/or computer tomography (CT) scan as the gold standard.

RESULTS

In the patients with suspicion of TC, the M371-Test showed a sensitivity of 73.7%, AFP of 21%, LDH of 31.6% and β-HCG of 42.1%. In the patients under follow-up for TC, the M371-Test showed a sensitivity of 86.4%, AFP of 50%, LDH of 31.8% and β-HCG of 63.6%. In germ cell tumours (GCT)/non-seminomas, M371-Test had a sensitivity of 83.3%, AFP of 77.8%, LDH of 38.9% and β-HCG of 66.7%. In GCT/seminomas, M371-Test had a sensitivity of 85%, AFP of 5%, LDH of 30% and β-HCG of 50%.

CONCLUSION

Under real life conditions performed on the real-time Thermocycler Rotor-GeneQ (Qiagen) platform, the M371-Test shows an outstanding performance and is far beyond the sensitivity of the classical markers for detecting GCTs and in the follow-up of patients after GCT, especially in seminomas.

Diagnostic value of Xpert® BC Detection, Bladder Epicheck®, Urovysion® FISH and cytology in the detection of upper urinary tract urothelial carcinoma

PURPOSE

Following the current guidelines, diagnosis and staging for upper urinary tract tumours (UTUC) can be performed with Computed Tomography, urography, ureterorenoscopy (URS) and selective cytology. The aim of the study was to evaluate the performance of the Xpert®-BC-Detection and the Bladder-Epicheck®-test in the detection of UTUC and compare it with cytology and the Urovysion®-FISH test using histology and URS as gold standard.

METHODS

A total of 97 analyses were collected through selective catheterization of the ureter before URS to test for cytology, Xpert®-BC-Detection, Bladder-Epicheck® and Urovysion®-FISH. Sensitivity, specificity, and predictive values were calculated using histology results/URS as reference.

RESULTS

Overall sensitivity was 100% for Xpert®-BC-Detection, 41.9% for cytology, 64.5% for Bladder-Epicheck® and 87.1% for Urovysion®-FISH. The sensitivity of Xpert®-BC-Detection was 100% in both, LG and HG tumours, sensitivity of cytology increased from 30.8% in LG to 100% in HG, for Bladder-Epicheck® from 57.7% in LG to 100% in HG and of Urovysion®-FISH from 84.6% in LG to 100% in HG tumours. Specificity was 4.5% for Xpert®-BC-Detection, 93.9% for cytology, 78.8% for Bladder-Epicheck® and 81.8% for Urovysion®-FISH. PPV was 33% for Xpert®-BC-Detection, 76.5% for cytology, 58.8% for Bladder-Epicheck® and 69.2% for Urovysion®FISH. NPV was 100% for Xpert®-BC-Detection, 77.5% for cytology, 82.5% for Bladder-Epicheck® and 93.1% for Urovysion®FISH.

CONCLUSION

Bladder-Epicheck® and Urovysion®FISH along with cytology could be a helpful ancillary method in the diagnosis and follow-up of UTUC while due to its low specificity Xpert®-BC Detection seems to be of limited usefulness.

Single staff cystectomy in a low-volume center: Oncological outcomes and complications

INTRODUCTION

Radical cystectomy (RC) with bilateral pelvic lymph node dissection (PLND) is a complex surgical procedure, associated with substantial perioperative complications. Previous studies suggested reserving it to high-volume centers in order to improve oncological and perioperative outcomes. However, only limited data exist regarding low-volume centers with highly experienced surgeons. We aimed to assess oncological and perioperative outcomes after RC performed by experienced surgeons in the low-volume center of Luzerner Kantonsspital, Lucerne, CH.

METHODS

We retrospectively analyzed data of 158 patients who underwent RC and PLND performed between 2009 and 2019 at a single low-volume center by three experienced surgeons, each having performed at least 50 RCs. Complications were graded according to the 2004 modified Clavien-Dindo grading system.

RESULTS

A total of 110 patients (70%) received an incontinent urinary diversion (ileal conduit or ureterocutaneostomy) and 48 patients (30%) received a continent urinary diversion (ileal orthotopic neobladder, ureterosigmoidostomy, or Mitrofanoff pouch). Median operating time was 419 minutes (interquartile range [IQR] 346-461). Overall, at RC specimen, 71.5% of patients had urothelial carcinoma ,12.6% squamous, 3.1% sarcomatoid, 1.2%glandular, and 0.6% small cell carcinoma. Median number of lymph nodes removed was 23 (IQR 16-29.5). Positive margins were found in eight patients (5.1%). Overall, five-year survival rate was 52.4%. The complication rate was 56.3%: 143 complications were found in 89 patients, 36 (22.8%) with Clavien ≥3. The 30-day mortality rate was 2.5%.

CONCLUSIONS

RC could be safely performed in a low-volume center by experienced surgeons with comparable outcomes to high-volume centers.

Immediate Shockwave Lithotripsy vs Delayed Shockwave Lithotripsy After Urgent Ureteral Stenting in Patients with Ureteral or Pyeloureteral Urolithiasis: A Matched-Pair Analysis

Introduction: The most common cause of acute renal colic is a ureteral obstruction caused by ureterolithiasis. Urgent intervention is often necessary due to intractable pain. Early extracorporeal shockwave lithotripsy (SWL) as an alternative treatment option to ureteral stenting becomes forgotten in times of rising ureterorenoscopy. However, definitive guidelines are lacking, in which urgent treatment should be preferred in the absence of signs of infection. Therefore, we assessed efficacy and safety of early SWL (eSWL) to secondary SWL (sSWL) after urgent ureteral stenting. Patients and Methods: One hundred four patients treated between January 2015 and November 2017 for obstructive ureterolithiasis were matched regarding stone size, stone localization, and assigned to group eSWL (n = 52) or group sSWL (n = 52). The eSWL group received shock waves (without prior ureteral stenting) and sSWL group ureteral stenting within 48 hours from diagnosis. Thereafter, patients in group sSWL were treated with shock waves for a median of 23 ± 14.6 days after ureteral stenting. Stone-free rates, complication rates, and reintervention rates were assessed. Univariable and multivariable logistic regression was applied to find predictors of outcomes in the two treatment groups. Results: Overall, there was no statistically significant difference between both groups regarding stone-free rate and complication rate. Reinterventions were more often addressed for patients in group sSWL (p = 0.05). eSWL was significantly superior to sSWL regarding stone-free rates for stones between 6 and 9 mm (p = 0.04). At the multivariable multinomial logistic regression none of the two treatment modalities was associated with better outcomes. A body mass index ≥30 was associated with a reduced 6-week stone-free status (p = 0.04), whereas stones ≥8 mm were associated with an increased need of reintervention (p = 0.04). Conclusion: eSWL seems to be an effective and safe emergency procedure compared with sSWL after urgent stenting within 6 weeks and should be considered as a treatment option in patients without absolute indications for immediate ureteral drainage. Clinical trial registration number: 2019-00155.

Diagnostic predictive value of the Bladder EpiCheck test in the follow-up of patients with non-muscle-invasive bladder cancer

BACKGROUND

The objective of this study was to evaluate the diagnostic accuracy of the Bladder EpiCheck test in the follow-up of patients with non-muscle-invasive bladder cancer (NMIBC) and to compare it with the accuracy of urinary cytology, cystoscopy, and/or histology.

METHODS

In total, 243 patients were enrolled in the current study. Patients were evaluated by voided urine cytology, by the Bladder EpiCheck test, and by white-light cystoscopy.

RESULTS

Overall sensitivity was 33.3% for cytology, 62.3% for Bladder EpiCheck, and 66.7% for the 2 tests combined. The sensitivity of cytology increased from 7.7% in low-grade (LG) tumors to 66.6% in high-grade (HG) tumors; whereas, for the Bladder EpiCheck test, the sensitivity was 46.1% in LG tumors and 83.3% in HG tumors. Combined cytology and Bladder EpiCheck testing yielded an overall sensitivity of 56.4% for LG tumors and 90% for HG tumors. Overall specificity was 98.6% for cytology, 86.3% for Bladder EpiCheck, and 85.6% for the 2 tests combined. The positive predictive value was 92% for cytology and 68.2% for Bladder EpiCheck. For the 2 tests combined, it was 68.6%. The negative predictive value was similar for the 2 tests: 75.8% for cytology, 82.9% for Bladder EpiCheck, and 84.5% for the 2 tests combined.

CONCLUSIONS

The sensitivity of the Bladder EpiCheck test was significantly higher than that of cytology. The test performed very well in terms of specificity but could not reach the high value of cytology. The positive predictive value was higher for Bladder EpiCheck, whereas the negative predictive value was approximately the same for both tests.

Safety and Effectiveness of Bipolar Transurethral Resection of the Prostate in Patients Under Ongoing Oral Anticoagulation with Coumarins or Antiplatelet Drug Therapy Compared to Patients Without Anticoagulation/Antiplatelet Therapy

Objective: To determine whether transurethral resection of the prostate (TURP) is safe and effective in patients under ongoing therapeutic oral anticoagulation (OAC) or antiplatelet drug (APD) therapy. Patients and Methods: We analyzed data on 276 consecutive TURP patients under ongoing APD therapy with acetylsalicylic acid (n = 130) or clopidogrel (n = 16) or ongoing OAC with phenprocoumon (n = 57), without stopping or bridging the medication, compared to 73 TURP patients without APD/OAC. Results: Outcomes of patients under acetylsalicylic acid were comparable to the controls. Under ongoing OAC therapy TURP patients tended to need slightly longer bladder irrigation (median 24 hours vs 22 hours, p = 0.06), needed longer transurethral catheterization (median 42 hours vs 24 hours, p = 0.031), were threefold more likely to have postoperative urinary retention (18% vs 6%, p = 0.04), had slightly longer hospital stays (median 4 days vs 3 days, p = 0.008), and tended to need more blood transfusions (9% vs 1%, p = 0.09), compared to controls. TURP patients under ongoing APD therapy with clopidogrel needed slightly longer bladder irrigation (median 24 hours vs 22 hours, p = 0.006), received more blood transfusions (19% vs 1%, p = 0.017), and had more rehospitalizations (19% vs 3%, p = 0.039). The significant functional improvement 1, 3, and 12 months after TURP was similar in all groups. Conclusions: Ongoing APD therapy with acetylsalicylic acid does not significantly impact TURP outcomes in terms of bleeding complications. Patients under ongoing therapeutic OAC with phenprocoumon or APD with clopidogrel can safely undergo TURP with an increased risk of bleeding complications, blood transfusions, and longer hospitalization.

The stone surgeon in the mirror: how are German-speaking urologists treating large renal stones today?

OBJECTIVE

To elucidate the current treatment strategies of LRS in German-speaking Europe. Little is known about the treatment of large renal stones (LRS > 3 cm) in daily urological practice. LRS therapy can be, however, challenging and hazardous.

MATERIALS AND METHODS

A 39 item web-based survey was performed among urologists listed by the German, Austrian and Swiss Associations of Urology, addressing professionals treating LRS "on their own" and working in a German-speaking country. Uniparametric descriptions indicated as absolute numbers and percentages without p values, simple linear associations and bubble plots without arithmetic means or bar charts with standard deviation between targeted parameters and percentages were used.

RESULTS

266 of the 6586 responding urologists claimed to treat urinary stones on a regular basis. The majority of them were male (90.2%) and over 50 years old (42.9%). Most stones are treated in non-university hospitals (69.5%). 81.9% of all the institutions treat more than 150 cases/y. Open surgery is still performed in 45.5% of the centres, laparoscopy in 32%. Percutaneous nephrolithotomy (PNL) is the primary treatment option. Antimicrobial strategies vary considerably. Serious complications seem to be rare. However, quite a few responders reported treatment-related deaths. The main limitation is the absolute number of urologists performing LRS treatment, which is unknown.

CONCLUSIONS

The German-speaking urologist treating LRS is a male and over 50. Although he performs PNL primarily, he is not averse to open surgery and SWL. He applies guidelines and employs modern equipment. Only antimicrobial strategies are out of line with the international standards.

Assessment of prostate cancer with integrated CT-perfusion using a sector-wise approach

OBJECTIVE

The role of computed tomography perfusion (CTP) in characterizing primary prostate cancer (PCa) is not definitely known. The aim of the present study was to investigate the relationship between CTP parameters and histopathological features of PCa tissue, using a sector-wise approach.

MATERIAL AND METHODS

Fifty-one patients with biopsy-proven PCa underwent prospectively a CTP scan prior to radical prostatectomy. Blood flow (BF), mean blood volume (BV) and mean transit time (MTT) were calculated, with the prostate being divided into eight sectors. Corresponding sector-wise histopathological analysis of whole-mount prostatectomy specimens was performed to determine tumoral area (mm²), mean microvessel density (MVD), Gleason patterns (primary, secondary) and total Gleason score. Spearman's rank correlation coefficient was used to analyze the association between CTP and histopathological parameters.

RESULTS

BF correlated weakly with tumoral area [ρs coefficient (p-value): 0.25 (0.00)] and MVD [ρs coefficient (p-value): 0.23 (0.00)]. No valuable correlation was found between CTP parameters and primary and secondary Gleason patterns, whereas total Gleason score was weakly correlated with BV [ρs coefficient (p-value): 0.22 (0.00)] and MTT [ρs coefficient (p-value): 0.25 (0.00)].

CONCLUSION

BF correlates weakly with size and vascularity of PCa. There is a need for further studies to elucidate the association between CTP parameters and other histopathological parameters.

Robot-assisted radical prostatectomy in the setting of previous abdominal surgery: Perioperative results, oncological and functional outcomes, and complications in a single surgeon's series

BACKGROUND

Data on safety and efficacy of robot-assisted radical prostatectomy (RARP) after previous abdominal surgery are scarce. Hence, we assessed perioperative, oncological and functional outcomes, and complications of RARP in patients with previous abdominal surgery after 1-year minimum follow-up.

MATERIALS AND METHODS

Prospectively collected data from 339 consecutive patients undergoing transperitoneal RARP by a single surgeon (AM) between November 2008 and May 2014 were analysed. Complications were classified according to Modified Clavien System. Biochemical recurrence (BCR) was defined as two consecutive PSA values ≥ 0.2 ng/ml. Functional outcomes were assessed using validated, self-administered questionnaires. In particular, only patients undergoing nerve-sparing RARP with no erectile dysfunction (baseline IIEF-5 score >21) and no use of phosphodiesterase-5 inhibitors preoperatively who were interested in erections and required no adjuvant therapy (radiation, orchiectomy and androgen-deprivation therapy) were evaluated concerning potency recovery. Patients without and with previous abdominal surgery were compared using Mann-Whitney and chi-square tests (or Fisher exact test).

RESULTS

On 339 patients, 247 (71.6%) had not undergone previous abdominal surgery (Group 1) and 92 (28.4%) were pre-operated (Group 2). There were no statistically significant differences between Groups 1 and 2 regarding mean operative time (260 vs. 257 min; p = 0.597), median number of resected nodes (16 vs. 17; p = 0.484), mean length of stay (7.2 vs. 7.1 d; p = 0.151), positive surgical margin (12.5% vs. 16.3%; p = 0.233) and complication rates (26.7% vs. 31.5%; p = 0.187). Median (IQR) follow-up was 36 (12-48) months. For Groups 1 and 2, BCR-free survival rates were 78.5% and 79.8% (p = 0.467); continence rates were 97.9% and 100% (p = 0.329), whereas a potency recovery was achieved in 69.5% and 62.2% of patients (p = 0.460), respectively.

CONCLUSIONS

Transperitoneal RARP is a safe and efficient treatment for clinically localised prostate cancer even in patients with previous abdominal surgery. However, further studies with higher number of patients are warranted.

Prospective Randomized Trial Comparing Titanium Clips to Bipolar Coagulation in Sealing Lymphatic Vessels During Pelvic Lymph Node Dissection at the Time of Robot-assisted Radical Prostatectomy

Lymphocele is the most common complication after pelvic lymph node dissection (PLND). Over the years, various techniques have been introduced to prevent lymphocele, but no final conclusion can be drawn regarding the superiority of one technique over another. In this prospective study, 220 patients undergoing robot-assisted radical prostatectomy between 2012 and 2015 were randomized to receive titanium clips (group A, n=110) or bipolar coagulation (group B, n=110) to seal lymphatic vessels at the level of the femoral canal during extended PLND (ePLND). Ultrasound examination was used to detect lymphoceles at 10 and 90 d after surgery. Lymphocele was defined as any clearly definable fluid collection and was considered clinically significant when requiring treatment. There were no statistically significant differences between groups A and B regarding overall lymphocele incidence (47% vs 48%; difference -0.91%, 95% confidence interval [CI] -2.6 to 0.7; p=0.9) and the rate of clinically significant lymphocele [5% vs 4%; difference 0.75%, 95% CI, 0.1-3.2; p=0.7]. The two groups were comparable regarding mean (±SD) lymphocele volume (30±32 vs 35±39ml; p=0.6), lymphocele location (unilateral, 37% vs 35%, p=0.7; bilateral, 13% vs 14%, p=0.9), and time to lymphocele diagnosis (95% vs 98% on postoperative day 10; p=0.5). In conclusion, this trial failed to identify a difference in lymphocele occurrence between clipping and coagulation of the lymphatic vessels at the level of the femoral canal during robot-assisted ePLND for prostate cancer.

PATIENT SUMMARY

In this study we compared the frequency of postoperative complications after sealing lymphatic vessels from the leg to the abdomen using metallic clips or electrical coagulation during robot-assisted surgery for prostate cancer. We found no difference in postoperative complications between the two methods.

Safety and Efficacy of Robot-assisted Radical Prostatectomy in a Low-volume Center: A 6-year Single-surgeon Experience

AIM

To analyze safety and efficacy of robot-assisted radical prostatectomy (RARP) in a low-volume centre.

PATIENTS AND METHODS

From 2008 to 2015, 400 consecutive patients undergoing RARP were prospectively enrolled. Complications were classified according to the Modified Clavien System. Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen (PSA) values ≥0.2 ng/ml. Functional outcomess were assessed using validated, self-administered questionnaires.

RESULTS

Median patient age was 64.5 years. Mean standard deviation (SD) preoperative PSA level was 11.3 (11.7) ng/ml. Median interquartile range (IQR) follow-up was 36 (12-48) months. Overall complication rate was 27.7% (minor complications rate 16.2%). Overall 1-, 3- and 6-year BCR-free survival rates were 85.7%, 77.5% and 53.9%, respectively; these rates were 94.1%, 86.2% and 70.1% in pT2 diseases. At follow-up, 98.4% of patients were fully continent (median (IQR) time to continence was 2 (1-3) months) and 68.2% were potent (median (IQR) time to potency of 3 (3-4) months).

CONCLUSION

RARP appears to be a valuable option for treating clinically localised prostate cancer also in a low-volume institution.

Extended pelvic lymph node dissection at the time of robot-assisted radical prostatectomy: Impact of surgical volume on efficacy and complications in a single-surgeon series

INTRODUCTION

We assessed the impact of surgical volume on perioperative outcomes and complications of robotic extended pelvic lymph node dissection (ePLND).

METHODS

From November 2008 to October 2012, a total of 233 consecutive patients with intermediate- or high-risk clinically localized prostate cancer underwent robot-assisted radical prostatectomy (RARP) and ePLND by a single, experienced open and laparoscopic surgeon. Data were prospectively collected. Complications were classified according to the Modified Clavien System. Complications potentially related to ePLND were documented. The minimum follow-up was 3 months. To evaluate the impact of surgical volume on the results, 4 patient subgroups (subgroup 1: cases 1-59; 2: 60-117; 3: 118-175; 4: 176-233) were compared using the Chi-squared and Kruskal-Wallis tests.

RESULTS

The mean (range) operative time for ePLND was 79 minutes (range: 48-144), with a steady performance over time (p = 0.784). The count of resected lymph nodes plateaued after 60 procedures (mean [range]: 13 [range: 6-32], 15 [range: 7-34], 17 [range: 8-41], 16 [range: 8-42] in Groups 1 to 4, respectively, p = 0.001). Tumour lymph node involvement was 12% in Groups 1 and 2, 7% in Group 3 and 9% in Group 4 (p = 0.075). Overall, 115 complications were reported in 98/233 patients (42%), with a significant decrease after 175 cases (p = 0.028). In Group 4, 3 patients reported an ePLND-related bleeding requiring open revision. Lymphoceles were detected in 10/233 patients (4.2%) and 1 patient (1.7%) in each of the Groups 2 to 4 required a percutaneous drainage.

CONCLUSIONS

A surgeon with extensive experience is expected to achieve a safe learning curve for ePLND during RARP. A learning curve of 60 cases is suggested for optimal lymph node yield.

First report on joint use of a Da Vinci® surgical system with transfer of surgical know-how between two public hospitals

INTRODUCTION

The costs of a Da Vinci® device for robot- assisted surgery, in particular for robot-assisted radical prostatectomy (RARP), can be a considerable issue for hospitals with limited caseloads.

MATERIALS AND METHODS

Since January 2011 the cantonal hospitals of Lucerne and St. Gallen (Switzerland) have shared a four-arm Da Vinci® device, transferring the surgical know-how by a Lucerne teaching surgeon to a St. Gallen surgeon. Complete pre- and perioperative data, including 3-month surgical RARP outcomes, were prospectively documented. For statistical analysis, Wilcoxon, exact Poisson and χ(2) tests were used.

RESULTS

During the first year, the two hospitals (61 RARP patients in Lucerne, 19 RARP patients in St. Gallen) did not differ significantly in preoperative, perioperative or oncological and functional results except for prostate volume (median 33 [interquartile range 24-40] vs. 40 [interquartile range 33-57] ml; p = 0.02), operation time (mean 252 ± 49 vs. 351 ± 50 min; p = 0.0001), number of lymph nodes removed (median 16 [interquartile range 13-21] vs. 15 [interquartile range 8-16] nodes; p = 0.02), biopsy (p = 0.04) and specimen Gleason scores (p = 0.03), and length of hospital stay (median 8 [interquartile range 7-14] vs. 9 [interquartile range 8-18] days; p < 0.01).

CONCLUSIONS

Da Vinci® device sharing with transfer of surgical know-how can reduce the costs of RARP without compromising surgical outcomes, even at the beginning of the learning curve.

Positioning injury, rhabdomyolysis, and serum creatine kinase-concentration course in patients undergoing robot-assisted radical prostatectomy and extended pelvic lymph node dissection

BACKGROUND AND PURPOSE

During robot-assisted radical prostatectomy (RARP), patients remain in a steep Trendelenburg position. This can cause positioning injuries as well as rhabdomyolysis. The primary diagnostic indicator of rhabdomyolysis is elevated serum creatine kinase (CK). We investigate whether RARP with extended pelvic lymph node dissection (ePLND) in a prolonged extreme Trendelenburg position can cause positioning injuries and rhabdomyolysis.

PATIENTS AND METHODS

We performed a prospective study of the first 60 patients undergoing RARP and ePLND for organ-confined prostate cancer at our institute. Positioning injuries were graded according to three degrees of clinical severity. Serum-CK, serum-pH, and base excess (BE) were measured before, during, and for 5 days after surgery. Rhabdomyolysis was defined by serum-CK levels >5000 IU/L.

RESULTS

Median operative time was 317 minutes (range 200-475 min); median time in the Trendelenburg position was 282 minutes (range 170-470 min). Serum-CK was significantly elevated 6 hours postoperatively, peaking at 18 hours postoperatively. Serum-CK levels did not correlate with pH, BE, and perioperative creatinine values. Serum-CK course shows weak correlation with body mass index (BMI), operative time, Trendelenburg position time, and medium correlation with positioning injuries of any degree. Twenty-one of the 60 (35%) patients showed positioning-related injuries: 16 (27%) patients degree I, 2 (3%) patients degree II, and 3 (5%) patients degree III. Rhabdomyolysis developed in 10 patients. Postoperative renal failure did not develop in any patient receiving postoperative hypervolemic diuretic therapy nor any patient with injuries degrees I, II, or III. conclusion: Clinically relevant positioning injuries and rhabdomyolysis can occur in patients who are subjected to prolonged extreme Trendelenburg position during RARP and ePLND, especially at the beginning of the learning curve. Serum-CK increases significantly after surgery, peaking 18 hours postoperatively. Serum-CK elevation alone is not predictive of positioning injury. By very long operative and Trendelenburg times as well as high BMI with visible position injuries, we recommend serum-CK measurement 6 and 18 hours postoperatively followed by hypervolemic therapy to prevent possible renal injury from rhabdomyolysis if serum-CK >5000 IU/L.

Bildgebung der Nieren und Harnwege

Bildgebende Verfahren sind in der urologischen Diagnostik äußerst wichtig. Bei der akuten Flankenkolik ist die häufigste Ursache ein obstruierender Harnleiterstein, welcher mittels Nativ-Computertomographie (CT) oder alternativ mittels intravenöser Urographie (IVU) abgeklärt wird. Bei Verdacht auf parenchymatösen Nierentumor wird eine CT durchgeführt, bei der Abklärung von Nierenbecken- oder Harnleitertumoren sind jedoch eine IVU gefolgt von einer retrograden Pyelographie mit Gewinnung einer selektiven, lokalen «Spülzytologie» der erste Schritt. Eine CT oder MRT des Abdomens/Beckens ist bei positivem Tumornachweis zum Staging (lokoregionäre oder systemischer Metastasierung?) notwendig und zeigt zudem auch die lokale Tumorsituation. Exophytische oder invasive Prozesse der Harnblase können zwar oft im CT oder Ultraschall gesehen werden, bei Verdacht auf einen Blasentumor ist die Primärdiagnostik aber die Zystoskopie, die durch die Bildgebung nicht ersetzt werden kann. Die Zystographie zeigt Verletzungen der Harnblase oder dient zusammen mit dem Miktionsbild zum Nachweis eines vesikoureteralen Refluxes. Bei Strikturen oder Verletzungen der Harnröhre ist das retro- und anterograde Urethrogramm die Abklärung der Wahl.

Is Antegrade Endopyelotomy Really Less Invasive than Open Pyeloplasty?

OBJECTIVE

We investigated the invasiveness of antegrade endopyelotomy and open pyeloplasty in two consecutive series of patients with ureteropelvic junction obstruction.

PATIENTS AND METHODS

98 patients were treated by open pyeloplasty from 1980 to 1991, and 137 patients by antegrade endopyelotomy from 1991 to 1999. Diagnosis of ureteropelvic junction obstruction was made by excretory urogram and/or antegrade pyelography, diuretic renography and retrograde pyelography. Invasiveness was evaluated by the postoperative need for analgesics, the complication rate and the residual long-term symptoms after surgery.

RESULTS

The postoperative need for opiate analgesics was significantly higher in patients after open pyeloplasty than after antegrade endopyelotomy. Ten percent of the patients complained of problems with the lumbotomy scar after open pyeloplasty, which was not encountered after endopyelotomy. Complications after open pyeloplasty occurred in 24% and were more severe than the 11% seen after endopyelotomy. The primary success rate after open pyeloplasty was 98 and 89% after antegrade endopyelotomy. The long-term success rate, > or = 24 month postoperatively, was 96% (median follow-up 37 (24-196) months) and 76% (median follow-up 32 (24-73) months), respectively.

CONCLUSION

Open pyeloplasty and endopyelotomy both have a high success rate with better patency results after open pyeloplasty. Open pyeloplasty is more invasive and has a higher morbidity. Endopyelotomy is a minimally invasive procedure with faster recovery, fewer and minor complications, significantly less need for peri- and postoperative analgesics, less residual pain due to the access, and no functional and esthetic sequelae of lumbotomy.

Extracorporeal shock wave lithotripsy of lower calyx calculi: how much is treatment outcome influenced by the anatomy of the collecting system?

OBJECTIVES

Extracorporeal shock wave lithotripsy (ESWL) of lower calyx stones has been criticized because of the high incidence of residual fragments. Controversial results have been reported regarding the stone-free rate after ESWL depending on the influence of the collecting system anatomy on stone clearance. Therefore we evaluated our stone-free rate after ESWL of lower calyx stones and searched for correlations to various anatomic parameters of the collecting system.

METHODS

Ninety-six patients with isolated lower calyx stones treated exclusively with ESWL (Dornier HM3) were evaluated 3 mo postoperatively. The results were correlated with the following anatomic parameters of the collecting system as determined from the pretreatment intravenous urography: (1) lower infundibulum width, (2) lower infundibulum length, (3) infundibulopelvic angle, (4) volume of the collecting system. Follow-ups were performed 24 h after ESWL with an abdominal plain film and 3 mo postoperatively with a urography or abdominal plain X-ray together with renal ultrasound.

RESULTS

Three months postoperatively, 68% of all patients were stone free, including 69% of the patients with stones initially < or =1 cm, and 67% of the patients with stones >1 cm. Stone-free patients compared with patients having residual fragments had no significant differences in infundibulum width, infundibulum length, infundibulopelvic angle, or collecting system volume.

CONCLUSIONS

A stone-free rate 3 mo after ESWL of 68% overall justifies ESWL as a possible treatment option for lower calyx stones. Influence of the collecting system anatomy on disintegrate clearance from the lower calyx could not be demonstrated.

Ultrasound Assessment of Detrusor Thickness in Men—Can it Predict Bladder Outlet Obstruction and Replace Pressure Flow Study?

PURPOSE

We estimated the diagnostic accuracy of ultrasound detrusor thickness measurement for BOO and investigated whether this method can replace PFS for the diagnosis of BOO in some patients with lower urinary tract symptoms.

MATERIALS AND METHODS

Detrusor thickness was measured by linear ultrasound (7.5 MHz) at a filling volume of greater than 50% of cystometric capacity in 102 men undergoing PFS for LUTS. All patients with prior treatment for bladder outlet obstruction and those with underlying neurological disorders were excluded from analysis. Detrusor thickness was correlated with PFS data. Obstruction was defined according to the Abrams-Griffiths nomogram.

RESULTS

Detrusor thickness was significantly higher (p <0.0001) in obstructed (61 cases, median detrusor thickness 2.7 mm, IQR 2.4 to 3.3) compared to unobstructed (18 cases, median detrusor thickness 1.7 mm, IQR 1.5 to 2) as well as equivocal (23 cases, median detrusor thickness 1.8 mm, IQR 1.5 to 2.2) cases. A weak to medium Spearman correlation was found between detrusor thickness and PFS parameters. For a diagnosis of BOO, detrusor thickness of 2.9 mm or greater had a positive predictive value of 100%, a negative predictive value of 54%, specificity of 100% and sensitivity of 43%. ROC analysis revealed that detrusor thickness had a high predictive value for BOO with an AUC of 0.88 (95% CI 0.81-0.94).

CONCLUSIONS

In men with LUTS without prior treatment and/or neurological disorders, ultrasonographically assessed detrusor thickness 2.9 mm or greater has a high predictive value for BOO and can replace PFS for the diagnosis of BOO. However, this cutoff value needs to be validated in a larger study population.

Antegrade Endopyelotomy for Treatment of Ureteropelvic Junction Obstruction in Transplanted Kidneys

BACKGROUND AND PURPOSE

Little is known about the incidence and treatment of ureteropelvic junction (UPJ) obstruction of renal grafts. We report on three cases treated by endopyelotomy.

PATIENTS AND METHODS

Graft function declined in three patients 98, 135, and 144 days after kidney transplantation. Acute rejection was excluded by renal biopsy. Ultrasonography revealed a dilated collecting system, and a percutaneous nephrostomy tube was placed. An antegrade nephrostogram showed UPJ obstruction. Percutaneous antegrade endopyelotomy was performed with the cold-knife technique, and the area was stented for 6 weeks using a 14F/8.2F Smith endopyelotomy stent.

RESULTS

No intraoperative or postoperative complications occurred. The endopyelotomies were successful, and the creatinine clearances returned to normal.

CONCLUSION

Antegrade endopyelotomy in patients with UPJ obstruction of a renal graft is feasible and effective. Normal kidney function was restored after correction of the obstruction.

Botulinum A toxin injections into the detrusor: an effective treatment in idiopathic and neurogenic detrusor overactivity?

AIMS

To assess and compare the effect of botulinum A toxin (BTX-A) injections into the detrusor in idiopathic and neurogenic detrusor overactivity resistant to anticholinergic treatment.

PATIENTS AND METHODS

In a prospective study, 11 patients with idiopathic and 11 with neurogenic detrusor overactivity resistant to anticholinergic treatment were injected with 300 U of BTX-A (Botox) into the detrusor. Clinical and urodynamic parameters were assessed before and after BTX-A injections.

RESULTS

In idiopathic as well as in neurogenic detrusor overactivity, median daytime frequency decreased significantly from 11 to 4 (P = 0.004) and 12 to 5 (P = 0.001), median nocturia from 3 to 1 (P = 0.004) and 3 to 1 (P = 0.001), and median number of used pads from 5 to 0 (P = 0.001) and 5 to 0 (P = 0.002), respectively. There was a significant increase in median maximum cystometric capacity from 220 to 340 ml (P = 0.001) and 190 to 410 ml (to instead of) (P = 0.001), median bladder compliance from 20 to 55 ml/cm H(2)O (P = 0.001) and 23 to 60 ml/cm H(2)O (P = 0.004) and median post void residual from 10 to 140 ml (P = 0.002) and 30 to 240 ml (P = 0.002), respectively. Median maximum detrusor pressure decreased significantly from 45 to 29 cm H(2)O (P = 0.002) and 40 to 24 cm H(2)O (P = 0.002), and median detrusor pressure at maximum flow rate from 30 to 14 ml/sec (P = 0.001) and 38 to 21 ml/sec (P = 0.016), respectively. Due to post void residuals >150 ml following BTX-A injections, de novo clean intermittent self-catheterization was necessary in nine patients (four with idiopathic and five with neurogenic detrusor overactivity) and in one patient (with idiopathic detrusor overactivity) a suprapubic catheter was placed. The effect of BTX-A injections lasted for a median time of 5 months in both idiopathic and neurogenic detrusor overactivity. There was no significant difference in idiopathic compared to neurogenic detrusor overactivity in regard to clinical and urodynamic parameters assessed before and after BTX-A injections.

CONCLUSIONS

BTX-A injections into the detrusor have a significant and comparable but temporally limited effect in idiopathic and neurogenic detrusor overactivity resistant to anticholinergic treatment.

IS NEWER ALWAYS BETTER? A COMPARATIVE STUDY OF 3 LITHOTRIPTOR GENERATIONS

PURPOSE

At a single center we compared the efficacy of 3 generations of lithotriptors using identical protocol inclusion and followup criteria but with different modes of anesthesia.

MATERIALS AND METHODS

We compared stone disintegration and dilatation of the pyelocaliceal system achieved in a prospective, randomized trial comparing the original HM3 (Dornier Medtech, Kennesaw, Georgia) and Lithostar Plus (LSP) lithotriptors, and a matched, consecutive series of 107 treatments with the Modulith SLX. Stone disintegration and dilatation of the pyelocaliceal system were evaluated by abdominal plain x-ray and renal ultrasonography 1 day and 3 months after treatment.

RESULTS

A total of 82 treatments with the HM3, 75 with the LSP and 107 with the SLX were analyzed, matched for stone burden and location within the pyelocaliceal system. On postoperative day 1, 91%, 65% and 48% patients treated with the HM3, LSP and SLX, respectively, were stone-free or had fragments that were 2 mm or less (HM3 vs LSP p <0.001, HM3 vs SLX p <0.001 and LSP vs SLX p = 0.015). Three to 5 mm fragments were found in 7%, 21% and 35% of patients (p = 0.006, <0.001 and 0.06), and fragments 6 mm or greater were found in 1%, 14% and 15% (p = 0.002, <0.001 and 0.1, respectively). The re-treatment rate was 4% in the HM3 group, 13% in the LSP group and 38% in the SLX group (HM3 vs LSP p = 0.05, HM3 vs SLX p <0.001 and LSP vs SLX p <0.001). Obstructive pyelonephritis occurred in 1% of the HM3 group, 8% of the LSP group and 5% of the SLX group (HM3 vs LSP p = 0.02, HM3 vs SLX p = 0.12 and LSP vs SLX p = 0.4). All re-treatments except those in 5 patients were performed with the HM3. Therefore, the 3-month stone-free rate was comparable in all 3 groups (HM3 87%, LSP 80% and SLX 81%).

CONCLUSIONS

This study indicates that the HM3 lithotriptor disintegrates caliceal and renal pelvic stones better than the LSP and SLX machines, resulting in fewer complications and re-treatments. Disintegration with the LSP machine was also superior to that of the SLX with a need for fewer re-treatments.

ATTEMPTED NERVE SPARING SURGERY AND AGE HAVE A SIGNIFICANT EFFECT ON URINARY CONTINENCE AND ERECTILE FUNCTION AFTER RADICAL CYSTOPROSTATECTOMY AND ILEAL ORTHOTOPIC BLADDER SUBSTITUTION

PURPOSE

We assessed factors influencing urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution.

MATERIALS AND METHODS

Of 381 consecutive men undergoing radical cystoprostatectomy and ileal orthotopic bladder substitution between April 1985 and June 2003, 331 (87%) met the inclusion criteria and were enrolled in the analysis. Kaplan-Meier models and multivariate analysis applying Cox regression were used to evaluate factors influencing postoperative urinary continence and erectile function.

RESULTS

In univariate analysis, attempted nerve sparing and age younger than 65 years were significantly associated with better daytime (p = 0.002 and p = 0.007, respectively) and nighttime continence (p = 0.036 and p = 0.005, respectively). In multivariate analysis the rate of daytime continence was significantly higher in patients with attempted nerve sparing (hazards ratio [HR] 1.4, 95% confidence interval [CI] 1.05-1.87) and nighttime continence was significantly better in patients younger than 65 years (HR 1.39, 95% CI 1.07-1.8). Daytime continence was significantly better (p <0.0001) and was achieved more quickly than nighttime continence (p <0.0001). The time to achieve daytime continence was shorter for patients with attempted nerve sparing (p = 0.012). In multivariate analysis erectile function recovered significantly more often in patients with attempted nerve sparing (HR 2.59, 95% CI 1.24-5.39) and in those younger than 65 years (HR 2.98, 95% CI 1.83-4.85).

CONCLUSIONS

After radical cystoprostatectomy and ileal orthotopic bladder substitution, attempted nerve sparing and age younger than 65 years are associated with improved urinary continence. Attempted nerve sparing has the greatest impact on daytime continence and age has the greatest impact on nighttime continence. Attempted nerve sparing and younger age are both associated with more frequent recovery of erectile function.