A. Wille

Laparoscopic radical prostatectomy—an analysis of factors affecting operating time

OBJECTIVESnAlthough laparoscopic radical prostatectomy (LRP) is accomplished within 2 to 3 hours by experienced surgeons, less is known about the operating times (OTs) for recently trained surgeons or the influence of additional factors. As of November 2001 at our institution, two senior surgeons had each performed more than 100 cases of LRP and two junior surgeons had each performed fewer than 30. We prospectively studied the next 100 consecutive LRPs to assess the factors influencing the OT.nnnMETHODSnTransperitoneal LRPs were performed by two senior (n = 62) and two junior surgeons (n = 38) with random case assignment. We assessed body mass index, prostate size, prior abdominal surgery, androgen deprivation, surgeon experience, procedures in addition to LRP, lymph node dissection, nerve sparing, and sural nerve grafting as potential predictors of the OT.nnnRESULTSnProstate weight, androgen deprivation, and prior abdominal surgery did not significantly affect the OT, but grade 1 obesity increased the OT by an average of 38 minutes. The mean OT by surgeon experience was 214 minutes for seniors and 347 minutes for juniors (P <0.001). By procedure type, the OT ranged from 180 minutes for LRP only by seniors to 459 minutes for LRP plus lymph node dissection plus sural nerve grafting by juniors. Lymph node dissection and sural nerve grafting significantly increased the OT by 46 and 101 minutes, respectively, and nerve sparing did not. For each combination of procedures, seniors averaged significantly shorter times than did juniors. A multiple regression model with stepwise selection showed that prostate weight, sural nerve grafting, pelvic lymph node dissection, use of a surgical robot, and surgeon experience significantly affected the OT.nnnCONCLUSIONSnThe results of this prospective study of 100 cases of LRP showed that the OT for senior surgeons averaged 2 to 3 hours, but less experienced surgeons, and additional procedures, add significantly to the OT.

Positive margins after laparoscopic radical prostatectomy: A prospective study of 100 cases performed by 4 different surgeons

OBJECTIVEnLaparoscopic radical prostatectomy (LRP) has been refined by experienced surgeons into a competitive treatment alternative for localized prostate cancer. Less is known, however, about the outcomes of learning curve cases from newly trained surgeons. We prospectively studied 100 cases of LRP performed by 2 senior and 2 junior surgeons and addressed the rates of positive margins-an important early endpoint of oncologic efficacy.nnnMETHODSn100 consecutive cases of LRP were performed by two senior (n=62) and two junior surgeons (n=38) by a 5-port transperitoneal route. Whole-mount step-section prostate specimens were examined by Stanford protocol.nnnRESULTSnPositive margins occured in 25% of cases: 18% for pT2a (2/11), 18% for pT2b (11/61), 45% for pT3a (10/22), and 50% for pT3b (2/4) (p=0.002 pT2 vs. pT3). By surgeon experience, the rates were 19% (12/62) for senior and 34% (13/38) for junior (p=0.04). However, in a multiple logistic regression analysis, only pathologic stage (p=0.083) and Gleason sum (p=0.0133) reached statistical significance, while surgeon experience did not (p=0.0992).nnnCONCLUSIONnPositive margin rates after laparoscopic radical prostatectomy are significantly influenced by pathologic stage and Gleason score, and are within the range reported from open series. The higher positive margin rate from junior surgeons, although not statistically significant, suggests the need for further study and continued mentoring during surgery and/or video review of cases to improve oncologic results.

Laparoscopic Partial Nephrectomy Using FloSeal for Hemostasis: Technique and Experiences in 102 Patients

Objectives. The authors report their techniques, perioperative data, and oncological outcome for laparoscopic partial nephrectomy in a single-center experience with 3 different surgeons. Patients and methods. A total of 102 consecutive patients underwent laparoscopic transperitoneal partial nephrectomy for exophytic tumors using FloSeal for hemostasis. Mean age was 58 years (range = 26-79 years), and median tumor size was 2.6 cm (range = 0.5-8.5 cm). In 84 cases, the renal artery was clamped using endoscopic bulldog clamps, and tumor resection was performed using scissors or the harmonic scalpel. Hemostasis was achieved by application of FloSeal; lesions of the collecting system were closed with Lahodny sutures in 33 cases (31%). Frozen sections were obtained for margin status. Results . All 102 procedures were successful with no intraoperative complications. Mean surgical time was 201 minutes (range = 60-355 minutes); clamping time was 25.8 minutes (range = 6-75 minutes) in 64 cases. Margins were negative in 92 cases; in 8 cases secondary resection was necessary to achieve negative margin status, and in 2 cases radical nephrectomy was performed. Histological findings were clear-cell carcinoma in 51 (50.0%), papillary carcinoma in 26 (25.5%), and others in 25 (24.5%) cases. At a mean follow-up of 32 months (12-62 months), no recurrence was observed. Conclusions. Laparoscopic partial nephrectomy with the use of FloSeal is a feasible and safe method for treatment of small renal masses. The technique is reproducible by surgeons who are used to complex laparoscopic procedures. Patient outcome during follow-up was comparable with data published for open standard procedures.

Tumor type M2 pyruvate kinase expression in metastatic renal cell carcinoma

The M2 isoenzyme of pyruvate kinase (M2-PK) is specifically expressed in tumor cells (TuM2-PK) and has been detected in the peripheral blood of patients with renal cell carcinoma (RCC). TuM2-PK is not useful as a biological marker in localized RCC. We analysed TuM2-PK in 68 patients with metastatic RCC after initial surgery and prior to or during chemoimmunotherapy of metastases. In 50 patients, the levels of TuM2-PK were measured during chemoimmunotherapy with interleukin-2, interferon-α2a and 5-fluorouracil for up to 8xa0months and were correlated to response as assessed by radiological imaging techniques. TuM2-PK was quantified with a commercially available enzyme linked immunosorbent assay kit using a cut off of 15xa0kU/l. In 48 of 68 patients (71%), TuM2-PK was elevated above the cut-off. TuM2-PK was significantly higher in G3 tumors than in G2 tumors. In 34 of 50 patients (68%) undergoing chemoimmunotherapy, a positive correlation between TuM2-PK values and response to treatment was observed. Based on these data, we would not recommend the routine clinical use of TuM2-PK in metastatic RCC at this point.

Diagnostic difficulties before definitive treatment of an extragonadal retroperitoneal germ cell tumor

A primary extragonadal germ cell tumor of the retroperitoneum was diagnosed in a 47-year-old man without elevated serum alpha-fetoprotein, human chorionic gonadotropin, or lactate dehydrogenase levels. The diagnosis was made by histologic analysis after resection. The patient responded well to a combination of cisplatin, etoposide, and ifosfamide, achieving a partial response with four cycles. Residual tumor resection revealed necrotic tissue only. The patient was alive and disease free 24 months after diagnosis. The diagnostic difficulties of this particular situation are discussed.

Kidney transplantation into urinary conduits with ureteroureterostomy between transplant and native ureter: single-center experience.

OBJECTIVESnTo evaluate the functional outcomes and complications after allogeneic kidney transplantation into recipients with a urinary conduit using ureteroureterostomy between the transplant and native ureter.nnnMETHODSnWe performed a retrospective study of 6 patients with a pre-existing urinary conduit undergoing kidney transplantation at a single tertiary academic center from May 1982 to February 2007.nnnRESULTSnThe study included 1 female and 5 males aged 16 to 65 years. Two patients received a living donor transplant. The indications for pretransplant conduit formation were neurogenic bladder in 3 and bladder contraction with vesicoureteral reflux in 3. One patient received a colon conduit. All patients underwent kidney transplantation into a urinary conduit using ureteroureterostomy between the transplant ureter and the ipsilateral native ureter. The average interval between conduit formation and kidney transplantation was 83.5 months and the average time of requiring hemodialysis was 56.3 months. The mean follow-up was 5.3 years. The patient and graft survival rate was 100% and 83.3%, respectively. The 3-year serum creatinine averaged 1.4 mg/dL. One graft was lost because of chronic rejection. Transplant ureter obstruction occurred in 2 patients and required endoscopy or open revision. Four patients underwent post-transplant native nephrectomy for recurrent pyelonephritis. Three patients were hospitalized for treatment of graft pyelonephritis.nnnCONCLUSIONSnIn our experience, ureteroureterostomy between the transplant and native ureter is technically feasible and provides good functional results despite a high incidence of urinary tract infection. We recommend this approach in renal transplant recipients with a short contracted conduit or in those in whom the donor ureter is too short to warrant a tension-free ureteroileal anastomosis.

[Coincidence of testicular germ cell tumor and sarcoidosis: A diagnostic challenge].

ZusammenfassungIn Fallberichten und kleinen Fallserien wurden bislang 66xa0Patienten mit Sarkoidose und Hodentumor in der Literatur dokumentiert. Anhand von 3 weiteren Fallberichten aus unserer Klinik wird die potentielle Problematik eines simultanen Auftretens von Sarkoidose und testikulären Keimzelltumor in Bezug auf die radiologischen und pathologischen Befunde diskutiert. Die Sarkoidose, die mit einem Keimzelltumor assoziiert sein kann, sollte stets in die Differentialdiagnose integriert werden.AbstractSeveral case reports and small case series have described a total of 66 patients with sarcoidosis and testicular cancer so far. This report describes three additional cases. We highlight the association of sarcoidosis and testicular cancer and comment on the potential impact of this connection on the interpretation of the radiological and pathological findings in suspected cancer relapse. Sarcoidosis, a condition that can be combined with testicular cancer, should always be considered in the differential diagnosis.

Testikulärer Keimzelltumor und Sarkoidose

ZusammenfassungIn Fallberichten und kleinen Fallserien wurden bislang 66xa0Patienten mit Sarkoidose und Hodentumor in der Literatur dokumentiert. Anhand von 3 weiteren Fallberichten aus unserer Klinik wird die potentielle Problematik eines simultanen Auftretens von Sarkoidose und testikulären Keimzelltumor in Bezug auf die radiologischen und pathologischen Befunde diskutiert. Die Sarkoidose, die mit einem Keimzelltumor assoziiert sein kann, sollte stets in die Differentialdiagnose integriert werden.AbstractSeveral case reports and small case series have described a total of 66 patients with sarcoidosis and testicular cancer so far. This report describes three additional cases. We highlight the association of sarcoidosis and testicular cancer and comment on the potential impact of this connection on the interpretation of the radiological and pathological findings in suspected cancer relapse. Sarcoidosis, a condition that can be combined with testicular cancer, should always be considered in the differential diagnosis.

Die laparoskopische transperitoneale Tumornephrektomie: Indikation, Technik und onkologisches Outcome

ZusammenfassungDie laparoskopische Tumornephrektomie hat in den letzten Jahren weltweite Verbreitung gefunden und ist in unserer Einrichtung eine Standardmethode der Therapie des Nierenzellkarzinoms. Dabei werden die klassischen Prinzipien der urologischen Onkologie unter Anwendung minimal-invasiver Techniken mit ihren Vorteilen umgesetzt.Die Erfahrungen während 100 Operationen haben gezeigt, dass trotz hoher Anforderungen an den Operateur der Eingriff sicher und effizient durchführbar ist. Der zunehmende Anteil größerer Tumoren, die laparoskopisch operiert werden konnten, ist dabei Ausdruck der gewachsenen Erfahrung mit der Technik. Die mittlere Tumorgröße betrug 5,9xa0cm mit einem Maximum von 11xa0cm. Nur in 2xa0Fällen (2%) zwangen intraoperative Komplikationen zur Konversion, in weiteren 3xa0Fällen (3%) konnte das Management laparoskopisch erfolgen. Der mittlere Blutverlust betrug 220xa0ml, die postoperative Liegedauer betrug im Mittel 6xa0Tage.Von 61xa0Patienten waren Follow-up-Daten verfügbar, wobei die mittlere Nachbeobachtungszeit 12,9 (2–30) Monate betrug. Während dieser Zeit erlitten 2xa0Patienten einen systemischen Progress; lokale Rezidive oder Portmetastasen traten in keinem Falle auf.Sowohl die klinischen Verläufe als auch die vorliegenden Daten aus der Nachsorge sprechen für das Konzept der laparoskopischen Nierenchirurgie. Unserer Meinung nach wird sich die laparoskopische Tumornephrektomie in der Zukunft zur Methode der Wahl bei der Therapie des lokal begrenzten Nierenzellkarzinoms entwickeln.AbstractRenal cell carcinoma is likely to become one of the most important indications for laparoscopic surgery worldwide. The laparoscopic technique combines the benefits of the minimally invasive approach with established surgical principles. In our institution the laparoscopic transperitoneal approach with intact specimen extraction has become the standard technique for radical nephrectomies. We report the indications, techniques, and oncological outcome in a single center experience in 100 cases.The mean tumor size was 5.9xa0cm (range: 2–11xa0cm), the blood loss was 220xa0ml, and the mean surgical time was 211xa0min, including the learning curves of five surgeons. Histological findings were pT1 in 66 (66%), pT2 in 11 (11%), and pT3 in 19 (19%) patients with an increasing tumor size according to the experience of the surgeons. In four cases (4%) histology did not prove malignant disease. Positive lymph nodes were detected in three cases (3%) and surgical margins were negative for tumor in all patients. To date 61 patients were available for follow-up; patients with primary metastatic disease were excluded from this analysis. Follow-up was between 1 and 30xa0months with an average of 12.9xa0months. Progressive disease occurred in two cases in patients with pT3G3 tumors. No cases of local recurrence or port metastasis occurred during observation.Laparoscopic radical nephrectomy is a routine, effective treatment for patients with renal cell carcinoma. Our follow-up data up to 30xa0months confirm the effectiveness of laparoscopic radical nephrectomy in terms of surgical principles and oncological outcome.

Kidney transplantation in childhood and adolescence

ZusammenfassungDie Ursachen der terminalen Niereninsuffizienz im Kindesalter unterscheiden sich deutlich von denen des Erwachsenenalters. Die Therapie der Wahl besteht in der Nierentransplantation. In Deutschland wurden im Jahre 2003 117 Kinder und Jugendliche nierentransplantiert. Spezifische Probleme bestehen in der Immunsuppression und den daraus resultierenden Komorbiditäten im Kindesalter. Der vorliegende Beitrag gibt eine Übersicht über die Möglichkeiten und Probleme der Vorbereitung, der Transplantation und des weiteren Verlaufs von Nierentransplantationen im Kindesalter.AbstractThe reasons for end-stage renal disease in pediatric patients differ from adults. The therapy of choice is renal transplantation. A total of 117 children and adolescents were treated with renal transplantation in 2003 in Germany. Immunosuppressive therapy and related comorbidities are the main problems in pediatric patients. The following article provides a summary of transplantation in children, preparation, and follow-up.