Bernhard Brehmer

Permanent 125I‐seed brachytherapy or radical prostatectomy: a prospective comparison considering oncological and quality of life results

To assess the quality of life in patients with prostate cancer after permanent brachytherapy (BT) or radical perineal prostatectomy (RP).

Percentage of positive biopsies predicts lymph node involvement in men with low-risk prostate cancer undergoing radical prostatectomy and extended pelvic lymphadenectomy

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

Different Types of Scaffolds for Reconstruction of the Urinary Tract by Tissue Engineering

Introduction: Tissue engineering is an important and expanding field in reconstructive surgery. The ideal biomaterial for urologic tissue engineering should be biodegradable and support autologous cell growth. We examined different scaffolds to select the ideal material for the reconstruction of the bladder wall by tissue engineering. Materials and Methods: We seeded mouse fibroblasts and human keratinocytes in a co-culture model on 13 different scaffolds. The cell-seeded scaffolds were fixed and processed for electron microscopy, hematoxylin and eosin stain, and immunohistochemistry. Cell density and epithelial cell layers were evaluated utilizing a computer-assisted optical measurement system. Results: Depending on the growth pattern, scaffolds were classified into the following three distinct scaffold types: carrier-type scaffolds with very small pore sizes and no ingrowth of the cells. This scaffold type induces a well-differentiated epithelium. Fleece-type scaffolds with fibers and huge pores. We found cellular growth inside the scaffold but no epithelium on top of it. Sponge-type scaffolds with pores between 20 and 40 µm. Cellular growth was observed inside the scaffold and well-differentiated epithelium on top of it. Conclusion: To our knowledge, this is the first time three distinct scaffold types have been reported. All types supported the cell growth. The structure of the scaffolds affects the pattern of cell growth.

Bladder wall replacement by tissue engineering and autologous keratinocytes in minipigs

To develop a tissue‐engineered bladder wall replacement with autologous cells and a biodegradable scaffold, as whenever there is a lack of native urological tissue the bladder is reconstructed with different bowel segments, which has inevitable complications.

Overactive bladder syndrome: an underestimated long-term problem after treatment of patients with localized prostate cancer?

Study Type – Therapy (case series)

Two‐ and three‐/four dimensional perineal ultrasonography in men with urinary incontinence after radical prostatectomy

Study Type – Diagnostic (case control)

Perioperative Morbidity of the Extended Radical Perineal Prostatectomy

Purpose: Perioperative morbidity is an essential indicator for the quality of an operative technique. This fact is especially important in radical prostatectomy since different treatment modalities may provide similar outcome in terms of local tumor control. Materials and Methods: The conventional type of radical perineal prostatectomy is associated with a significant percentage of positive surgical margins and was therefore substituted by a modified extended radical perineal prostatectomy at our institution. This procedure which includes partial resection of the dorsal vein complex and extrafascial resection of the seminal vesicals was performed in 200 patients with clinical T1 to T3 prostate cancer. The medical records were retrospectively reviewed for perioperative morbidity. Results: There was no perioperative mortality and only 7% of the patients experienced postoperative complications. Blood substitution was indicated in 14% of the patients and could be reduced to 4% in the last 50 patients. The reintervention rate was 2.5% including 3 patients in whom a rectocutaneous fistula had to be repaired. The suction drainage was removed in 92% patients within 5 days. The indwelling catheter stayed in place for less than 14 days in 89% of all patients and was removed as early as after 2–7 days in 92% of the last 50 patients. Anastomotic strictures were observed in 8 (5%) of 160 patients followed for more than 6 months. 87.4% of patients were considered continent after at least 6 months follow–up. However, pad use was reported in 33.6%. Conclusion: The extended type of radical perineal prostatectomy provides excellent results in terms of perioperative morbidity, although a significant learning curve can be noted, which is indicated by blood substitution and duration of necessary catheter drainage. Since the rate of positive surgical margins in pT3 tumors is low (21%) and iatrogenic positive margins in pT2 tumors are avoided, this type of prostatectomy should be performed in case a potency sparing procedure is not indicated.

Die erweiterte, radikale perineale Prostatektomie

Zusammenfassung125 konsekutive Patienten mit Adenokarzinom der Prostata wurden einer erweiterten radikalen perinealen Prostatektomie entsprechend der Technik von Weldon unterzogen. Diese Technik wurde durch die primäre komplette Mobilisation der Prostatahinterfläche und der Samenblasen, der Inzision der Faszia endopelvina, der queren Inzision der Denonvillier-Faszia am Apex und der partiellen Durchtrennung des dorsalen Venenkomplexes nach vorangegangener Durchstechungsligatur modifiziert.Die perioperative Morbidität war gering. Eine operative Wundrevision war bei 4 (3,2%) der Patienten wegen subkutaner arterieller Blutung aus dem Drainagekanal (n=1), Wundinfekt (n=2) und rektokutaner Fistel (n=1) erforderlich. Der Dauerkatheter wurde bei 104 (83%) Patienten am 4.–8. Tag entfernt. Positive Schnittränder fanden sich nur bei 22 (17,6%) Patienten. Es handelte sich dabei um 17 pT3- und 5 pT4-Tumoren mit Gleason-Score ≥7 (n=17), ausgedehntem, multifokalem Kapseldurchbruch (n=18), Infiltration der Samenblasen (n=11) und Lymphknotenmetastasen (n=4). Die unifokal positiven Schnittränder fanden sich am Apex (n=3), dorsolateral (n=6) und am Blasenhals (n=4); 9-mal lag ein multifokal positiver Schnittrand vor.Die Wahrscheinlichkeit des positiven Schnittrandes ist abhängig vom Serum-PSA, Gleason-Score und Tumorvolumen. Wird auf eine Potenzerhaltung verzichtet, so wird zur Vermeidung von positiven Schnitträndern die erweiterte radikale perineale Prostatektomie mit den angegebenen Modifikationen empfohlen.AbstractOne hundred and twenty-five consecutive patients with prostate cancer underwent an extended, radical perineal prostatectomy according to the technique described by VE Weldon. This technique was modified by an initial complete mobilization of the posterior aspect of the prostate and seminal vesicles from the rectum and pelvic wall, incision of the endopelvic fascia, and partial resection of the dorsal vein complex after suture ligature. The perioperative morbidity was low.An operative revision was necessary in four (3.2%) patients because of arterial bleeding from a drainage channel (n=1), wound infection (n=2), and rectocutaneous fistula (n=1). The in-dwelling catheter was removed on day 4–8 in 104 (83%) patients. Positive surgical margins were diagnosed in 22 (17.6%) patients only. These patients had pT3 (n=17) and pT4 (n=5) tumors with a Gleason score ≥7 (n=17) mostly; extensive, multifocal capsular penetration (n=18); seminal vesicle invasion (n=11); and lymph node metastases (n=4). The unifocal positive margins were localized at the apex (n=3), dorsolateral (n=6) aspect, and bladder nech (n=4). In nine patients, multifocal positive surgical margins were noted.The risk for a positive surgical margin depends on the serum PSA level, Gleason score, and tumor volume. In case potency prservation is not considered, the extended, radical perineal prostatectomy with the above mentioned modifications should be considered to guarantee a low rate of surgical margins.

Radical Prostatectomy in Patients with Previous Groin Hernia Repair Using Synthetic Nonabsorbable Mesh

Objective: Identification of patients in whom the perineal route is the optimal approach to perform radical prostatectomy. Material and Methods: During 1992–1999, 376 patients with prostate cancer underwent radical perineal prostatectomy. Four patients were identified in whom the perineal approach was indicated because of previous bilateral groin hernia repair using synthetic meshes. In addition, 1 patient underwent perineal prostatectomy elsewhere for similar reasons. Results: The perineal approach offered an uneventful surgical solution for an adequate and straightforward radical perineal prostatectomy without complications and without biochemical recurrence during the follow-up. Conclusion: Radical perineal prostatectomy is suggested to be the optimal approach in patients with previous bilateral groin hernia repair using synthetic, nonabsorbable meshes.

[Metastasectomy in renal cell cancer after neoadjuvant therapy with multi-tyrosine kinase inhibitors].

BACKGROUND Metastatic renal cell carcinoma (mRCC) still poses a challenge to therapists in spite of the availability of multiple innovative molecular treatment options. Complete remission is rare and in cases of partial remission it is often unclear if necrosis or vital carcinoma tissue persists. We report on a cohort of patients who underwent metastasectomy after neoadjuvant therapy with multi-tyrosine kinase inhibitors (MTKI). METHODS In 2009 a total of 11 patients (7 male and 4 female) underwent metastasectomy after achievement of ≥ 3 months stable partial remission. All patients received either sunitinib (n=7, mean 5.5 cycles), bevacizumab and interferon (IFN)-α2a (n=2, mean 8.5 months), temsirolimus (n=1, mean 9 months) or a combination of sunitinib followed by temsirolimus (n=1). Of the patients 7 presented with retroperitoneal lymph node metastases with a mean diameter of 3.5-12 cm, 2 patients with pulmonary metastases, 1 patient with lymph node and pancreas tail metastases and 1 female patient showed residual disease in the vena cava. RESULTS All metastases were completely resected with negative surgical margins. In 82% of the cases histologically active, Ki-67 positive renal cell cancer tissue was identified. The following adjunctive interventions were necessary: vena cava resection with vascular prosthesis and reimplantation of the renal vein (n=3), partial liver resection (n=1), splenectomy (n=1) and pancreas tail resection (n=1). There were no significant perioperative complications but 1 patient developed fascial dehiscence and underwent revision surgery and 1 patient developed clinically insignificant pancreatitis. After a median follow-up of 12 months (range 8-19 months) 5 patients had no recurrence and 6 of the patients showed liver (n=3), lung (n=2) or bone (n=1) recurrences from which 3 patients died. CONCLUSIONS Metastasectomy of mRCC is associated with a low rate of complications in experienced centers. Surgical resection of metastatic disease is indicated to achieve complete remission with a favorable prognosis because of biologically active kidney cancer tissue. Patients with isolated and resectable metastases are ideal candidates for such a procedure.