D. Schnorr

Laparoscopic radical prostatectomy—an analysis of factors affecting operating time

OBJECTIVES Although 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. METHODS Transperitoneal 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. RESULTS Prostate 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. CONCLUSIONS The 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.

Anwendung der optischen Kohärenztomographie (OCT) bei der Darstellung von Urothelerkrankungen der Harnblase

PURPOSE The technique of optical coherence tomography (OCT) has significantly improved over the last few years. This new diagnostic procedure allows imaging of tissue structure of the bladder wall during cystoscopy with high resolution. MATERIALS AND METHODS The penetration depth of OCT is limited to 2.5 mm. The resolution is approximately 15 microm. Fifty patients with different clinical conditions of the bladder were examined. Altogether 488 OCT images were generated. RESULTS OCT of normal bladder mucosa clearly shows a differentiation between urothelium, lamina propria, and smooth muscle. Cystitis and metaplasia are characterized by blurring of the laminated structure and thickening of the epithelial layer. In malignant areas there is complete loss of the regular layered tissue structure. CONCLUSION OCT improves the diagnosis of flat lesions of the urothelium. It has the potential for facilitating intraoperative staging of malignant areas in the bladder.

Utilizing optical coherence tomography (OCT) for visualization of urothelial diseases of the urinary bladder

PURPOSE The technique of optical coherence tomography (OCT) has significantly improved over the last few years. This new diagnostic procedure allows imaging of tissue structure of the bladder wall during cystoscopy with high resolution. MATERIALS AND METHODS The penetration depth of OCT is limited to 2.5 mm. The resolution is approximately 15 microm. Fifty patients with different clinical conditions of the bladder were examined. Altogether 488 OCT images were generated. RESULTS OCT of normal bladder mucosa clearly shows a differentiation between urothelium, lamina propria, and smooth muscle. Cystitis and metaplasia are characterized by blurring of the laminated structure and thickening of the epithelial layer. In malignant areas there is complete loss of the regular layered tissue structure. CONCLUSION OCT improves the diagnosis of flat lesions of the urothelium. It has the potential for facilitating intraoperative staging of malignant areas in the bladder.

Dispersion compensation for proximal scanning rigid OCT endoscopes

Combining endoscopy with optical coherence tomography (OCT) can improve the diagnosis in minimal invasive procedures. Up to now OCT probes were constructed using rotating or moving single-mode fibers or micro scanners at the tip of the probe. We describe an endoscopic OCT system which uses a specially designed rigid endoscope with an extracorporal scanner to create OCT images with 15 μm resolution. The OCT endoscope was constructed using a 270 mm gradient index lens with a diameter of 3 mm. Dispersion of the endoscope was compensated in the OCT interferometer by an all fiber approach. The system is now being tested for detecting malignancies in the urinary bladder.

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.

Nierentransplantation im Kindes- und Jugendalter

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.

Ex vivo and in vivo topographic studies of bladder by optical coherence tomography (Invited Paper)

Conventional imaging modalities like CT or ultrasonography have a spatial resolution of 70-1000 rim. OCT is a new method by which light of a certain wavelength is introduced into a fiberglass optic to measure tissue structures of up to 2.5 mm depth with a spatial resolution of up to 10-15 μm. We utilized the Tomograph Sirius 713, developed at the Medical Laser Centre in cooperation with 4-Optics AG, Lubeck, Germany. This apparatus uses a special Super- Luminescence-Diode (SLD) that produces light within the near infrared wavelength, with a central wavelength of 1300 nm. The coherence length is reduced to 15 μm. The light is introduced into a fiberglass optic which is several meters long and is easy to handle. To measure the depth of invasion and position of urothelial bladder tumors, the fiberglass optic is attached to a regular endoscope (Wolf, Knittlingen, Germany) via an OCT adapter. That way, in parallel to the regular endoscopic view of the bladder mucosa with or without pathologic findings, an OCT picture of the superficial as well as the deeper muscle layers is visible online. OCT was used to obtain 945 images from the bladder in vivo und ex vivo of 65 patients. OCT of normal bladder mucosa allows to image a cross section of up to 2.5 mm. It is possible to distinguish transitional epithelium, lamina propria, smooth muscles and capillaries. In cystitis, the thickness of the mucosa is constant, but the distinction between the different layers is blurred. In squamous metaplasia there is thickening of the epithelial layer, with preservation of lamination of the lower layers. In transitional cell carcinoma there is a complete loss of the regular layered structure. It is easily possible to distinguish the border between tumour and normal bladder tissue. OCT is a new high-resolution imaging procedure. It has the potential to improve the diagnostics of the urothelium and its lesions. In conjunction with a highly sensitive orientating procedure like fluorescence-cystoscopy, intraoperative staging of these changes could be possible in the future.

Anwendung der optischen Kohärenztomographie (OCT) bei der Darstellung von Urothelerkrankungen der Harnblase@@@Utilizing optical coherence tomography (OCT) for visualization of urothelial diseases of the urinary bladder

PURPOSE The technique of optical coherence tomography (OCT) has significantly improved over the last few years. This new diagnostic procedure allows imaging of tissue structure of the bladder wall during cystoscopy with high resolution. MATERIALS AND METHODS The penetration depth of OCT is limited to 2.5 mm. The resolution is approximately 15 microm. Fifty patients with different clinical conditions of the bladder were examined. Altogether 488 OCT images were generated. RESULTS OCT of normal bladder mucosa clearly shows a differentiation between urothelium, lamina propria, and smooth muscle. Cystitis and metaplasia are characterized by blurring of the laminated structure and thickening of the epithelial layer. In malignant areas there is complete loss of the regular layered tissue structure. CONCLUSION OCT improves the diagnosis of flat lesions of the urothelium. It has the potential for facilitating intraoperative staging of malignant areas in the bladder.

Confocal reflectance imaging of excised malignant human bladder biopsies

To evaluate the potential of reflectance confocal scanning laser microscopy (CM) for rapid imaging of non-processed freshly excised human bladder biopsies and cystectomy specimens. Freshly excised bladder tumors from three cystectomy specimens and random biopsies from twenty patients with a history of superficial bladder tumors were imaged with CM. Additional acetic acid washing prior to CM imaging was performed in some of the samples. Confocal images were compared to corresponding routine histologic sections. CM allows imaging of unprocessed bladder tissue at a subcellular resolution. Urothelial cell layers, collagen, vessels and muscle fibers can be rapidly visualized, in native state. In this regard, umbrella cells, basement membrane elucidated. Besides obvious limitations partly due to non-use of exogenous dyes, CM imaging offers several advantages: rapid imaging of the tissue in its native state like the basement membrane, normally seen only by using immunohistopathology. Reflectance CM opens a new avenue for imaging bladder cancer.

The effects of visual fluorescence marking induced by 5-aminolevulinic acid for endoscopic diagnosis of urinary bladder cancer

During cystoscopy procedure, fluorescence diagnostics induced by 5-ALA improves visual detection of the bladder cancer. Macroscopic ALA-fluorescence allows visualizing of small flat tumors, carcinoma in situ, true neoplasm margins and dysplasias of the bladder. Following ALA instillation, cystoscopy has been performed under both standard and blue light illumination. Totally, 153 biopsies have been carried out at 53 patients with suspicion of bladder cancer. The results were compared to ALA-fluorescence data. In 13% of the patients, bladder cancer and dysplasia were found out in addition, due to red fluorescence. The sensitivity and specificity of ALA-fluorescence technique aggregated 96% and 52% respectively. The sensitivity and specificity of 5-ALA-fluorescent detection exceeded standard endoscopy under white light on 20%. The new method does not exclude a false positive and a false negative fluorescent luminescence. The ALA-based fluorescence detection system enhances the diagnosis of malignant/dysplastic bladder lesions significantly.