Daniel Pfalzgraf

Open Retropubic Reanastomosis for Highly Recurrent and Complex Bladder Neck Stenosis

PURPOSE We assessed the success rate of open reanastomosis for highly recurrent bladder neck stenosis resistant to transurethral treatment. Due to the paucity of available data the success rate of this procedure is not well defined, although it can be a last treatment option before urinary diversion. MATERIALS AND METHODS A total of 158 patients were treated for bladder neck stenosis in 1998 to 2007, of whom 20 underwent open reanastomosis for highly recurrent or complex bladder neck stenosis after radical prostatectomy and were seen for followup 3 months postoperatively. They received a standardized questionnaire at the time of data acquisition in this retrospective analysis. RESULTS The 20 patients underwent a mean of 3.7 previous surgeries. Median followup was 59.2 months. Stenosis recurred after reanastomosis in 8 patients (40%) while the remaining 60% were recurrence free. Seven recurrences were successfully treated endoscopically, resulting in an overall combined 95% success rate. Urinary diversion was performed in 1 patient with another recurrence after reanastomosis and transurethral resection. Four patients (31%) had new onset incontinence and 13 were completely incontinent, of whom 9 were successfully treated with artificial urinary sphincter implantation. In another patient artificial urinary sphincter implantation is scheduled and 3 elected no further treatment. CONCLUSIONS Open reanastomosis for recurrent bladder neck stenosis is a good therapeutic option in cases of endoscopic treatment failure. The initial success rate after reanastomosis was 60%, which increased to 95% after secondary treatment. There was a relatively high risk of new onset incontinence after reconstructive surgery but this was successfully treated with artificial urinary sphincter implantation in most patients.

Short-Term Outcome and Morbidity of Different Contemporary Urethroplasty Techniques—A Preliminary Comparison

BACKGROUND AND PURPOSE Only few comparative reports about different urethroplasties have been published, addressing success rate (SR), adverse events (AE), and quality of life (QoL). Our purpose was to evaluate SR, AE, and QoL in a contemporary cohort of patients undergoing urethroplasty in the short-term follow-up (FU). PATIENTS AND METHODS Between December 2008 and June 2010, 205 patients underwent urethroplasty for anterior urethral strictures at our institution. A standardized questionnaire was sent to all patients. The primary end point was SR. Secondary end points were AE and QoL. To assess the risk of SR, the Kaplan-Meier method and log-rank test were used. To assess risk factors for urethral stricture recurrence (SRec), univariable Cox regression analysis was used. RESULTS Overall, 140 (68%) patients responded to our questionnaire and were used for analysis. Of these 9%, 85%, and 6% were treated by excision and primary anastomosis (EPA), buccal mucosa graft urethroplasty (BMGU), and mesh graft urethroplasty (MGU), respectively. At 10 months of FU, SR was 87.5%. SRs of EPA, BMGU, and MGU were 100% (n=13/13), 85.7% (n=102/119), and 87.5% (n=7/8), with no significant differences between the groups. In univariable analysis, ≥ 2 vs 1 previous urethroplasties showed a trend toward a reduced SR (hazard risk 2.95; P=0.057). Streaking the urethra (P=0.024) and penile curvature (P=0.026) were significantly more often associated with MGU compared with EPA and BMGU. Postoperative total median (mean) scores were 3.5 (4.8) for the International Consultation on Incontinence Questionnaire Male lower urinary tract symptoms, 15 (15.2) for the International Index of Erectile Function, and 80 (73) for EuroQol visual analogue score; there was no difference between urethroplasty types. CONCLUSION In the short-term FU, urethroplasty demonstrates an excellent SR. Specific SRs of EPA, BMGU, and MGU seem comparable. Despite significant differences in AE, patient reported QoL is high with no difference between the applied techniques.

Defining Renal Masses: Comprehensive Comparison of RENAL, PADUA, NePhRO, and C-Index Score.

Micro‐Abstract The study compares 4 established nephrometry systems—RENAL, PADUA, NePhRO, and C‐index—for their significance in predicting surgical outcome of partial nephrectomy in a cohort of 305 patients. All scores showed high association with surrogates of surgical complexity such as ischemia time or violation of the collecting system. Only RENAL, PADUA, and NePhRO score could predict postoperative complications. Background: Nephrometry scores are designed for standardized reporting of renal tumors and predicting complications. Multiple scores are available, but there is a lack of systematic comparison. Patients and Methods: A total of 305 consecutive patients admitted for open partial nephrectomy to 2 urological hospitals were prospectively assessed. Five cases with conversion to radical nephrectomy were excluded from further analysis. RENAL, PADUA, C‐index, and NePhRO scores were obtained from preoperative sectional imaging. Additionally, interobserver variance between 2 urologists and a radiologist was analyzed for 50 patients. Linear and ordered logistic regression was used to evaluate the association between scores and surgical parameters. Receiver operating characteristic analysis was employed to assess the predictive value for requirement of ischemia and opening of the collecting system. Results: High interobserver agreement was observed for RENAL (0.92 and 0.80), PADUA (0.81 and 0.85), NePhRO (0.94 and 0.82), and the C‐index (0.98 and 0.95). All scores showed a significant association with opening of the collecting system (P < .016), requirement of on‐clamp excision (P < .001), and ischemia time (P < .001). Logistic regression identified RENAL, PADUA, and NePhRO score to be an independent predictor for severe complications (P = .016, P = .011, and P = .005). No correlation was found for the C‐index (ß = 0.98; P = .779). Predictive effectiveness for opening of the collecting system and for on‐clamp excision showed comparable area under the curve values for the 4 scores. Conclusion: All scoring systems represent objective and reproducible measurement tools for renal tumor complexity, that correlate well with surgical outcome. RENAL, PADUA, and NePhRO score are comparable and seem to be superior to the more complex C‐index system.

Dorsal buccal mucosal inlay for penile urethroplasty

We present a modification of the original technique that simplifies the anastomosis and accelerates the whole procedure. buccal mucosal graft is sutured to the tunica albuginea using interrupted sutures, the right mucosal margin of the urethra is sutured to the right side of the graft, the urethra rotated back and the left urethral margin sutured to the left side of the graft. A 16 F catheter is left in place [1].

ZIRK-Technique: Zero Ischemia Resection in the Kidney for High-Risk Renal Masses: Perioperative Outcome

Objectives: This study evaluates the feasibility and safety of open-partial nephrectomies in the ZIRK-technique (Zero Ischemia Resection in the Kidney) for renal masses with high-risk anatomical features - objectified by the PADUA score. Methods: We identified 40 consecutive cases of partial nephrectomies performed without clamping of the renal artery in our department of urology. Retrospective analysis of the preoperative CT or MRI scans showed 27 cases with a PADUA score ≥8, of which 15 cases had a score ≥10. Cases were in particular assessed regarding operation time (ORT), estimated blood loss (EBL), surgical margins and postoperative complications using the Clavien classification. Results: The mean age of the study population was 67.6 years with an average BMI of 26.8 kg/m2. The mean ORT was 1:46 with an average EBL of 521 ml. Clavien grade II complications were observed seven times, while 3 patients had a grade IIIa complication. Despite complex and adverse location of the tumors, nephron-sparing surgery without ischemia could be performed with negative surgical margins for all cases. EBL, transfusion rate and complication were considerably more frequent in high-risk tumors. Conclusion: Highly complex renal tumors, PADUA ≥10, can be resected in ZIRK-technique with good operative outcome and a low complication rate.

Outcomes after recto‐anastomosis fistula repair in patients who underwent radical prostatectomy for prostate cancer

To assess fistula recurrence rate and health‐related quality of life (HRQL) after repair, as well as the impact on continence and erection in patients with recto‐anastomotic fistula after radical prostatectomy (RP). In recent publications, the numbers of cases of recto‐urinary fistulae after RP are relatively small. Success rates at fistula closure are good; however, data about functional outcomes and HRQL are more restricted.

Tumor size and invasiveness matters for partial nephrectomy: External validation and modification of the arterial based complexity score

Outcome of partial nephrectomy (PN) depends on anatomic features of the renal tumor, which can be assessed by nephrometry scores. The aim was to externally validate and refine the Arterial Based Complexity (ABC) score and to compare it to established systems.

Etiology and outcome of the perineal repair of posterior and bulbar urethral strictures in children: A single surgeon experience

OBJECTIVE To evaluate the etiology of posterior and/or bulbar strictures in children in an industrialized country and assess the outcome of its repair by perineal approach. Urethral strictures in children are rare and often challenging to treat. Trauma is the main etiology in developing countries. However, data for industrialized countries are sparse. MATERIAL AND METHODS Retrospective analysis of 17 patients treated with perineal urethroplasty 2001-2010. Data were assessed by chart review and non-validated standardized questionnaire. Hypospadias cases were excluded. Reconstruction was performed by stricture excision and primary anastomosis, or a single-staged or two-staged buccal mucosa graft. RESULTS Mean age at surgery was 7.9 years (range 1-13) and mean follow-up was 42.6 months (4-115). Eight patients (47.1%) had post-traumatic strictures, five (29.4%) had a history of posterior valves, and previous transurethral catheterization and irradiation each accounted for one patient (5.9%). In the remaining two (11.8%), the etiology was unknown. The success rate was 88.9%. All but one patient were continent postoperatively. CONCLUSIONS Most common etiology for open urethral reconstruction in children was trauma and previous valve treatment. In our hands the perineal approach for stricture repair is safe and successful. Stricture recurrence rate is low, and incontinence is only associated with additional bladder neck trauma.

Impact of Altered WNT2B Expression on Bladder Wall Fibroblasts: Implications for Apoptosis Regulation in the Stroma of the Lower Urinary Tract

Background: Little is known about the role of WNT signalling in pathological processes involving the urinary tract stroma. Here the impact of WNT signalling on bladder wall fibroblasts (BWFs) was studied using integrated expression profiling. Material and Methods: WNT ligand and downstream WNT pathway component expression was profiled in human BWFs using qRT-PCR. Highly expressed WNT2B was knocked down using siRNA in BWFs. The expression of 730 mRNAs and 800 miRNAs was analyzed on the nCounter MAX platform in #WNT2B and control transfected BWFs. qRT-PCR was used for validation in vitro and in matched scar and healthy bladder wall tissue samples of 12 patients with vesico-urethral anastomotic stricture (VUAS). Results: Thirteen genes and 9 miRNAs showed differential expression in #WNT2B cells. Among these were TNFSF10, a key apoptosis inductor, (0.22fold, p = 0.011) and miR-1246 (36.2fold, p = 0.031). miRNA target prediction indicated TNFSF10 to be regulated by miR-1246. qRT-PCR analysis confirmed differential expression of miR-1246 and TNFSF10 in #WNT2B BWFs. Furthermore, TNFSF10 was significantly underexpressed in VUAS tissue (p = 0.009). Conclusion: Perturbation of WNT signalling results in an altered expression of the apoptosis inductor TNFSF10. Similar changes are observed in VUAS. Further studies investigating the crosslink between WNT signalling and apoptosis regulation in the urinary tract stroma are warranted.

Evaluating the efficacy and tolerability of mirabegron, a β3-adrenoceptor agonist, for the treatment of overactive bladder: Systematic review and network meta-analysis:

Purpose: Overactive bladder (OAB) is a common condition affecting approximately 11% of individuals worldwide. One of the newest treatment options for OAB symptoms is mirabegron. The objective of this network meta-analysis is to evaluate the extent of the efficacy and tolerability of mirabegron compared both to placebo and first-line anticholinergic pharmacotherapies. Methods: Articles were identified through the MEDLINE, EMBASE, and Cochrane databases using the search term ‘mirabegron’. All original, prospective, randomised, controlled, double-blind clinical trials studying mirabegron in adults receiving initial treatment for OAB were included. Efficacy was assessed based on outcome variables and responder data. Tolerability was evaluated for reported adverse events. Results: Thirteen studies including a total of 13,333 individuals were included. Mirabegron demonstrated better efficacy compared to placebo and tolterodine extended release 4 mg. Compared to placebo, the incidence of tachycardia and nasopharyngitis was greater with mirabegron 50 mg, and the incidence of cardiac arrhythmia was greater in 100 mg treatment groups. Mirabegron 100 mg also demonstrated a lower incidence of cardiac arrhythmia compared to tolterodine. Conclusions: The current study presents new information that may affect patient-centred strategies for the management of OAB, with a particular concern for cardiovascular safety.