Axel Haecker

Validation of computer-based training in ureterorenoscopy

To evaluate the outcome of training both urological novices and experts, using the recently developed UroMentor (Simbionix Ltd, Israel) trainer, that provides a realistic simulation of rigid and flexible ureterorenoscopy (URS).

Thulium:yttrium-aluminium-garnet laser prostatectomy in men with refractory urinary retention

To evaluate the feasibility and efficacy of thulium:yttrium‐aluminium‐garnet (YAG) laser prostatectomy in patients with an indwelling transurethral catheter due to recurrent urinary retention secondary to benign prostatic obstruction.

Standardized Comparison of Prostate Morcellators Using a New Ex-Vivo Model

BACKGROUND AND PURPOSE Transurethral laser enucleation of the prostate is a common therapeutic option for the treatment of benign prostate enlargement. Evacuation of the enucleated tissue from the bladder is usually performed by electric morcellators. Until now, a standardized evaluation of the different morcellator settings does not exist. Therefore, we developed an ex-vivo model to find the best settings for four different morcellators. MATERIALS AND METHODS We morcellated pieces of a prostate adenoma after an open adenomectomy. The same speed settings were used to morcellate commercially available minced meat, fine pork sausage meat, and bovine heart, all of which had been cooked for 10 minutes using a Piranha Morcellator. We also morcellated raw pig perirenal fat tissue, raw pig liver, and raw bovine heart. The pieces were morcellated at different speed settings in an open water tank filled with saline. Because raw bovine heart showed to be the most equivalent tissue, we morcellated five pieces with four different settings of four different morcellators: The Piranha, the VersaCut, and two morcellator prototypes. RESULTS The median retrieval rate for the prostate adenoma was 14.02 (3.7-19.8) g/min. The retrieval rate for raw bovine heart was 13.75 (5.66-20) g/min. The maximum morcellation rates of the morcellators were: Piranha 20 (19.3-21.4) g/min, VersaCut 10.8 (8.2-13.1) g/min, Karl Storz prototype 9.8 (7.9-10.76) g/min, and Richard Wolf prototype 38.6 (35.3-42.9) g/min. CONCLUSION Raw bovine heart tissue is suitable for ex-vivo testing of prostate morcellators and can replace human prostate tissue in this standardized setting. In our ex-vivo study, the morcellation rates of the different morcellators increased with optimized oscillation speed and suction power settings. This needs to be confirmed in clinical studies.

Diverticular Carcinoma of the Urinary Bladder: Diagnosis and Treatment Problems

Objectives: To report a case of a primary carcinoma arising in a vesical diverticulum. Clinical Presentation and Intervention: A 59-year-old male patient presented with painless macrohematuria. A primary carcinoma arising in a vesical diverticulum was detected with cystoscopy and confirmed with rectal endosonography and computer tomography. and radical cystoprostatovesiculectomy with ileal conduit was performed. Chemotherapy with cisplatin and methotrexate followed. The patient died of an acute cardiac event in the 4th postoperative month.Conclusion: This report illustrates that in a case of a closed opening of a bladder diverticulum, rectal endosonography and computer tomography do provide additional support for making a diagnosis of a hidden tumor in the diverticulum.

Changes of Stage, Predictive Factors and Adjuvant Treatment Modalities in Seminomatous Testicular Cancer from 1987 to 2007 and Their Impact on the Status of Metastasis, Recurrence-Free and Overall Survival: A Single-Center Analysis

Introduction: To observe the changing presentation of seminomatous testicular cancer (STC), placing particular emphasis on predictive factors with a view to evaluating their impact on the status of metastasis, recurrence-free survival (RFS) and overall survival (OAS). Materials and Methods: 180 patients with STC were evaluated retrospectively. Four study periods were generated and compared for changes. The data were analyzed for predictive factors for metastasis. Mean follow-up was 83 months (range 10–246, patients alive = 146). Results: The number of STC patients increased constantly throughout 2007. From 1992 onwards, significantly more patients were diagnosed as being in CS1 (p = 0.001). The odds ratio (OR) of metastasis was significantly higher for pT3 than pT2 STC (OR 12.4 vs. 1.7; p = 0.003); pT1 tumors showed a lower risk factor. The 10- and 15-year RFS were 91 and 85%, respectively. Patients in clinical stages higher than CS1 (CS>1) had significantly reduced RFS (p < 0.001). The 5- and 10-year OAS were 97 and 96%, respectively. Patients in CS>1 had significantly reduced OAS rates (p = 0.013). Conclusions: The number of STC cases is increasing, particularly in the case of patients in CS1. This emphasizes the need for surveillance regimens and makes the evaluation of predictive factors for metastasis, recurrence and survival essential.

Lymph vessel density in seminomatous testicular cancer assessed with the specific lymphatic endothelium cell markers D2-40 and LYVE-1: Correlation with pathologic parameters and clinical outcome

OBJECTIVES To evaluate the role of lymph vessel density (LVD) and lymphangiogenesis in seminomatous testicular cancer (STC) by using the lymphatic endothelial cell (LEC) markers LYVE-1 and D2-40. METHODS AND MATERIALS Paraffin embedded tumor specimens from 40 patients with STC were stained by specific D2-40 and Lyve-1 antibodies. LVD was measured in different representative and standardized areas. Fluorescence double immunostaining for Lyve-1 and Ki-67 was performed and results were correlated with clinicopathologic data. The median follow-up period was 55 (range 10-135) months. RESULTS Mean intratumoral LVD (D2-40: 1.30 ± 1.99; Lyve-1: 1.82 ± 2.34) was significantly lower than peritumoral LVD (D2-40: 4.94 ± 2.58; Lyve-1: 4.62 ± 2.73) and LVD in nontumoral areas (D2-40: 4.81 ± 3.79; Lyve-1: 4.22 ± 3.19). There was no significant difference between LVD measures when using D2-40 or LYVE-1. Detection rates of lymphatic vascular invasion (LVI) were significantly higher than in conventional HE-stained sections (77.5% vs. 52.5%). No proliferating lymphatic vessels were found. CONCLUSIONS We found that LVD is decreased within tumor areas of STC. Despite a higher peritumoral LVD, no signs of proliferating endothelial cells were observed, suggesting a lack of lymphangiogenesis in STC. Detection of LVI can be optimized by specific D2-40 or LYVE-1 staining.

During twenty years of Cisplatin-based therapy the face of nonseminomatous testicular germ cell tumors is still changing: an evaluation of presentation, management, predictive factors and survival

PURPOSE To assess the changing presentation and treatment of nonseminomatous testicular germ cell tumors (NSGCT) and to investigate predictive factors for the status of metastasis at diagnosis and on relapse and death. MATERIALS AND METHODS Retrospective record review of 147 patients that underwent inguinal orchiectomy from 1987-2007. Follow-up data was available for 102 patients (median follow-up: 80 months (0-243); 96 patients alive). RESULTS Mean patients age increased (p = 0.015) and more patients were diagnosed in clinical stage I (CSI) (p = 0.040). The fraction of yolk sac (YS) elements inclined (p = 0.030) and pT2 tumors increased (p < 0.001). Retroperitoneal lymph node dissection (RPLND) declined whereas more patients were treated with chemotherapy (p < 0.001; p = 0.004). There was an increase in relapse free (RFS) and cancer specific survival (CSS) due to an improvement in patients with disseminated disease (p = 0.014; p < 0.001). The presence of YS and teratoma elements showed a reduction in the odds ratio (OR) for metastasis at diagnosis (p = 0.002, OR: 0.262; p = 0.009, OR: 0.428) whereas higher pT-stage was associated to their presence (p = 0.039). Patients with disseminated disease (CS > I) showed a declined CSS compared to CSI patients (p = 0.055). The presence of YS elements was associated to an improved RFS (p = 0.038). CONCLUSIONS In our single institution study the face of NSGCT markedly changed over 20 years even after the introduction of Cisplatin-based chemotherapy. These changes were accompanied by an improvement in RFS and CSS. When dealing with NSGCT patients such observations now and in the future should be taken into account.

Microvascular Invasion of Testicular Nonseminomatous Germ Cell Tumors: Implications of Separate Evaluation of Lymphatic and Blood Vessels

PURPOSE We separately evaluated the lymphatic and blood vascular systems to assess the diagnostic accuracy of microvascular invasion and identify predictive markers for occult metastasis of testicular nonseminomatous germ cell tumors. MATERIALS AND METHODS Tissue samples of 86 patients treated for testicular nonseminomatous germ cell tumors (stage 1 in 48 and stage greater than 1 in 38) were stained using the lymphatic endothelial cell specific marker LYVE-1 and the blood vessel endothelial cell marker von Willebrand factor. We assessed lymph vessel density in LYVE-1 stained sections and blood vessel density in von Willebrand factor stained sections. Lymphovascular invasion in LYVE-1 stained sections and blood vascular invasion in von Willebrand factor stained sections were documented. Parameters were correlated with standard clinicopathological data. RESULTS Blood vessel density in von Willebrand factor sections was significantly greater than lymphatic vessel density in LYVE-1 sections (p<0.001). Peritumor and nontumor lymphatic vessel density in LYVE-1 sections was associated with metastasis at diagnosis (OR 1.277/U, p=0.020 and OR 1.113/U, p=0.095). Lymphovascular invasion in LYVE-1 sections was significantly associated with metastasis (OR=4.517, p=0.002) but blood vascular invasion in von Willebrand factor sections was only slightly significant (OR 2.261, p=0.071). Only lymphovascular invasion in LYVE-1 stained sections was significantly associated with metastasis in a multiple logistic regression model. Microvascular invasion in hematoxylin and eosin stained sections was not associated with metastasis but microvascular invasion evaluated in LYVE-1 and von Willebrand factor stained sections was associated with metastasis (OR 3.506, p=0.016). CONCLUSIONS Lymphovascular invasion in LYVE-1 stained sections was the most important predictive parameter for metastasis at diagnosis, suggesting greater relevance of the lymphatic system in metastatic dissemination of testicular nonseminomatous germ cell tumors. Vascular endothelial cell specific markers provide higher diagnostic accuracy for microvascular invasion. Our results may impact the current concept of microvascular invasion used for risk stratification of clinical stage 1 testicular nonseminomatous germ cell tumors.

Persistence, Recurrence, and Progression Rates of Superficial Bladder Tumours after Resection Using the Differentiated Technique

Objective: To investigate whether the differentiated resection technique for excising superficial bladder cancer leads to higher recurrence and progression rates as compared with regular resection. Subjects and Methods: We evaluated 163 patients, 66 undergoing a differentiated and 97 a regular resection. All patients underwent a routine second resection within 6–10 weeks. Recurrence and progression rates as well as tumour persistence on second resection were analyzed. Results: Patients with differentiated resections of bladder tumours did not have higher tumour recurrence and progression rates. Also, these patients had a significantly higher percentage of tumour-free second resections (p = 0.03). Conclusion: The differentiated resection technique for excising superficial bladder cancer has no negative influence on recurrence and progression rates, but it leads to a reduced tumour persistence.

1277 IN VITRO EFFICACY OF HOLMIUM:YAG LASER LITHOTRIPSY IN NON FLOATING STONES. - EFFECT OF PULSE FREQUENCY, ENERGY AND LENGTH -

INTRODUCTION AND OBJECTIVES: Holmium:YAG (Ho:Yag) laser lithotripsy is the gold standard in endoscopic stone treatment. Aim of this study was to evaluate the influence of pulse frequency, power and length on the effectiveness of Ho:Yag laser lithotripsy using two different artificial stone compositions in-vitro. METHODS: Three different Ho:Yag laser devices (Sphinx, RevolixDuo (both LisaLaser, Germany) and Odyssey 30 (Cook, Ireland) were tested. The devices were used at different pulse energy rates (1 and 2 Joule) and frequency settings (5 and 10 Hz) all resulting in an output power of 10W, respectively. Where possible (Sphinx and Odyssey 30), pulse length was modified (350 vs. 700 msec). The light was transmitted via flexible 365 m fibers. Experiments were performed in a water bath using cone shaped artificial stone (20ml volume) consisting of a soft stone composition (plaster of paris; Quick-mix, Germany) and a hard stone composition (Fujirock type 4 dental stone; GC Europe, Belgium). Lithotripsy was performed for 60 sec in contact mode on fixed stones applying 600 W in total per setting. Stones were dried for 72 h; fine granulated sand was used to measure the volume of the craters. Sample size was n 10 for all settings using hard stones, and n 6 when using soft stones. Unpaired t-test was used for statistical analysis. RESULTS: In all of the 5 tested groups per stone type, a slower pulse rate but increased pulse energy (5 Hz/ 2 J vs. 10 Hz/1 J) resulted in a higher stone disintegration. At 5 Hz/ 2 J Ho:Yag laser lithotripsy was more effective applied on hard stones ( 27.46% (10-55.4%); all p 0.05) and on soft stones ( 33.62% (8-54.3%); 3 of 5 tested groups p 0.05) compared to the 10 Hz/ 1 J setting. Furthermore, reduction of the pulse length from 700 to 350 msec resulted in a significantly higher stone disintegration ( 71.58% (57-120.6%); all p 0.05) in soft stone composition in 4 tested groups. In hard stone composition, reducing the pulse length was associated with a significant higher stone disintegration ( 27.25% (23.8-30.7%); all p 0.05) in combination with higher pulse energy (2 J/ 5 Hz). At lower pulse energy (1 J/ 10 Hz), the increased stone disintegration rate was not significant ( 6,5% (6.4-6.5%), p 0.05, respectively). CONCLUSIONS: Our results indicate that higher pulse energy and shorter pulse length increase disintegration rates of Holmium:YAG laser lithotripsy when retropulsion is excluded in vitro. This may help to improve efficacy of Holmium:YAG laser lithotripsy in non floating stones in vivo.