Gralf Popken

Laparoscopic adrenalectomy in urological centres – the experience of the German Laparoscopic Working Group

Study Type – Practice patterns (retrospective cohort)

Surgical Outcomes of Fluorescence-Guided Laparoscopic Partial Nephrectomy Using 5-Aminolevulinic Acid-Induced Protoporphyrin IX

BACKGROUND To evaluate the clinical performance of photodynamic diagnostic (PDD) after oral administration of 5-aminolevulinic acid (5-ALA) for assessment of tumor type and surgical margins in laparoscopic nephron-sparing surgery. MATERIALS AND METHODS This is a prospective, non-randomized single-center study. A total of 77 patients with a renal mass < 4 cm diameter underwent laparoscopic partial nephrectomy (LPN). For photosensitization, 1.5 g 5-ALA was administered orally 4 h prior to surgery. During the operation, the resection site and the outer tumor border were inspected under excitation light for characteristic red fluorescence. The results of PDD were matched up to the histological findings. RESULTS Mean operative time was 94.1 min with a mean warm-ischemia time of 23 min. Fifty-eight of 61 (95.1%) renal cell carcinomas showed a positive response when exposed to excitation light. In 16 cases (21%), final pathology revealed a nonmalignant lesion. However, characteristic fluorescence was also detected in 1 angiomyolipoma of 16 nonmalignant lesions. False-negative rate was 3/61 (4.9%) and false-positive rate was 1/77 (1.3%), with these data corresponding to a sensitivity of 95% and a specificity of 94%. Further, PDD with 5-ALA was able to predict the type of the lesion with an accuracy of 94% and with a positive predictive value of 98%. Furthermore, PDD with 5-ALA also identified both cases with positive resection margins, which were confirmed on histological examinations. No side effects of systemic 5-ALA administration were observed. CONCLUSIONS PDD after systemic administration of 5-ALA is a reliable tool to assess the type and the resection status of a suspected renal tumor during laparoscopic nephron-sparing surgery.

Penile Venous Surgery for Cavernosal Venous Leakage: Long–Term Results and Retrospective Studies

From February 1987 to September 1991, 122 men with erectile impotence and confirmed cavernosal venous leakage underwent penile venous surgery. After a postoperative follow-up of 36 months, only 18.8% of the patients had satisfactory erections without further therapy. Another 32.5% postoperatively converted to responders to intracavernous injection therapy with vasoactive drugs. Therefore, a total of 51.3% benefitted from the operation. Dynamic pharmacocavernography proved to be the most important examination in terms of establishing indication and prognosis. According to our results, there are two basically different forms of cavernosal venous leakage with different postoperative outcomes: primary and secondary corporeal incompetence. In many cases, an arterial cofactor was determined.

Intravesical administration of 5-aminolevulinic acid (5-ALA) Safety and pharmacokinetics of 5-ALA and its metabolite protoporphyrin IX

AbstractObjective: In an open study, the local and systemic side effects and pharmacokinetics of 5-aminolevulinic acid (5-ALA) and the fluorescent metabolite protoporphyrin IX (PPIX) were investigated after intravesical administration for the fluorescent photodetection of superficial bladder carcinoma. Patients and methods: In 20 patients with confirmed bladder carcinoma, 5-ALA was introduced into the bladder 2 h (15 patients) and 4 h (5 patients) before an elective endoscopic resection. The 5-ALA and PPIX levels in the plasma were determined before and up to 10 h after application, and in the urine 2 h or 4 h after application. Results: The plasma level of 5-ALA rose rapidly, the maximal concentration (340 ng/ml) being reached in 0.55 h (2 h) or 0.62 h (4 h). The elimination half-life of 5-ALA amounted to 0.74 h (2 h) or 0.79 h (4 h). In five of the patients, there was a measurable plasma concentration which ranged from the detection limit of 4.3 ng/ml to 14 ng/ml between 2 h and 5 h after application, and then fell below the detection limit after 9 h. Absorption of 5-ALA by the bladder was low, i.e. less than 1% of the total amount applied. During a period of observation of 96 h, no 5-ALA-specific side effects appeared. Conclusion: Because of the small quantity of 5-ALA resorbed following its intravesical administration, only minimal concentrations of PPIX that are responsible for producing side effects can be metabolised in the plasma. Therefore, no systemic side effects are to be expected after the intravesical administration of 5-ALA.

Intraoperative photodynamic evaluation of surgical margins during endoscopic extraperitoneal radical prostatectomy with the use of 5-aminolevulinic acid.

PURPOSE Today there are no established techniques to image positive surgical margins (PSM) intraoperatively in endoscopic extraperitoneal radical prostatectomy (EERPE). The intention of this study was to describe the specific technique of photodynamic diagnosis (PDD) in patients undergoing EERPE and report on the potential to detect PSM under PDD. MATERIALS AND METHODS Twenty-four patients with clinically organ-confined prostate cancer received 5-aminolevulinic acid 20 mg/kg body weight orally 3 hours prior to nonnerve-sparing EERPE. An endoscopic PDD system (Karl Storz, Tuttlingen, Germany) including a Tricam PDD 3-chip camera head linked with a straight 10-mm telescope and a D-light C system was used. During EERPE, visualization of the surgical margins was performed by means of both white light and PDD at specific steps during standardized prostatectomy in all patients. Positive PDD areas on the prostate specimen were marked with white ink and consequently processed in pathology. RESULTS In white light endoscopy, no suspicion of a PSM was raised. Six out of the eight PSM were detected by PDD. In two cases, areas of positive PDD findings were free of prostate cancer and two PSM were not detected by PDD ( one bladder neck, one lateral). The overall sensitivity and specificity were 75% and 88.2%, respectively. CONCLUSIONS Laparoscopy offers an appropriate setting for the use of PDD in prostate cancer to visualize possible PSM. Although imaging of PSM by PDD is promising with the technique being feasible and safe, larger series are needed to prove the reproducibility of our results.

Microsurgical epididymovasostomy in the rat: comparison of end-to-side and two invagination techniques

Abstract Most cases of obstructive azoospermia are caused by epididymal obstruction for which the classical treatment is epididymovasostomy (EVST). We have compared the widely used end-to-side, invaginated end-to-side and invaginated end-to-end operations. Ninety microsurgical two-layer EVST were carried out on rats. The technical advantages were assessed and patency of anastomoses and conception rate, the length of the operation and amount of suture material used measured in each group. There were no significant differences in patencies and conception rate between the three groups. The invagination techniques took significantly less time than the more usual end-to-side operation, and less suture material was used. The invagination techniques are easier to learn, simpler to perform and involve less manipulation, reduce trauma and cause less laceration to the ductus deferens and epididymal tubules. Economically considered, the operations save the expenditure of both time and suture material. Of paramount importance in making the choice is the size of the ductus deferens and that of the epididymal tubules.

Performing radical cystectomy and urinary diversion in regional anesthesia: potential risk reduction in the treatment of bladder cancer.

Objective: To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA), avoiding the adverse effects of general anesthesia. Materials and Methods: In our hospital, radical cystectomy with extended pelvic and iliac lymphadenectomy and urinary diversion was performed on 28 patients using CSTEA without applying general anesthesia, in 2011 and 2012. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Outcome measurements included operative time, blood loss, start of oral nutrition, start of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), postoperative complications according to the Clavien-Dindo classification and length of hospital stay. Results: All surgical procedures were performed without any complications and caused no anesthesiologically or surgically untoward effects. We observed no more severe complications than grade 1 according to the Clavien-Dindo classification. Conclusions: Our data show that CSTEA is an effective and safe technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks, especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes and complications of CSTEA.

Cystectomy and urinary diversion in the treatment of bladder cancer without artificial respiration

PURPOSE To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA). MATERIALS AND METHODS In 2011 radical cystectomy with extended pelvic and iliac lymphadenectomy was performed on 14 patients using urinary diversion without applying general anesthesia. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Postoperatively, pain management took three days with the remaining epidural catheter before oral analgesics were administered. Mobilization and diet restoration were carried out according to the fast-track concept. Outcome measurements included operative time, blood loss, beginning of oral nutrition, beginning of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), length of hospital stay. RESULTS All surgical procedures were performed without any complications. The absence of general anesthesia did not result in any relevant disadvantages. The postoperative progress was normal in all patients. Particularly, cardiopulmonary complications and enteroparesis did not occur. The provided palliative care proved sufficient (NAS max. 3-4). Discharge followed 10 to 22 days after surgery. At the time of discharge, the patients described the procedure to be relatively positive. CONCLUSIONS Our data show that CSTEA is an effective technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes, and complications of CSTEA.

Asystolic cardiac arrest during balloon insufflation for endoscopic extraperitoneal radical prostatectomy.

BACKGROUND AND PURPOSE Hemodynamic changes during abdominal laparoscopic procedures have been described as multifactorial phenomena. We report the possible occurrence of bradycardia and asystolic cardiac arrest during insufflation of the balloon trocar as a rare and serious but reversible complication during endoscopic extraperitoneal radical prostatectomy (EERP) for management of localized prostate cancer. PATIENTS AND METHODS Between 2003 and 2006, 430 patients underwent EERP for localized prostate cancer. The anesthetic protocol was standardized. The EERP was started with creating a preperitoneal space by insufflation of air through a balloon trocar inserted tangentially to the cutaneous plane toward the pubis. RESULTS Review of the intraoperative data of our patient population revealed the occurrence of bradycardia and/or asystolic cardiac arrest during insufflation of the balloon trocar in three patients. The overall incidence of this complication in our population was therefore 0.7 per 100 patients. Further, during the insufflation of the balloon, a maximum pressure of 120 mm Hg has been measured. CONCLUSIONS Severe vagal reaction triggered by manipulation of pelvic structures or nerves by the insufflated balloon trocar resulted in asystolic cardiac arrest in three patients. The life-threatening nature of this phenomenon should be understood by all anesthesiologists and urologists engaged in laparoscopic procedures.

Maintaining Perioperative Normothermia During Laparoscopic and Open Urologic Surgery

PURPOSE The ability to maintain normothermia during surgical procedures is crucial for improvement of the quality of patient care and the outcome of the procedure. We tested the hypothesis of whether one warming protocol is able to maintain normothermic core temperatures equally well in major open and laparoscopic urologic procedures. PATIENTS AND METHODS In this prospective study, 300 patients who were scheduled for open (n=53) or laparoscopic (n=247) urologic procedures were included and received intraoperative warming using a combination of an upper and lower body forced-air warmer and a single warming blanket. Core temperature was measured at baseline, at induction of anesthesia, at the start of the operation, and at the end of the operation. RESULTS A significant improvement in core temperature during the operation was achieved in all patients (P<0.001). There was no difference in the end-of-operation core temperature between laparoscopic and open procedures: (36.29 degrees C+/-0.03 degrees C v 36.23 degrees C+/-0.06 degrees C; P=0.224). Further, 23.3% of all patients had a core temperature of lower than 36.0 degrees C at the end of the operation (laparoscopy 23.8% v open 26.6%). Linear regression analysis revealed a correlation between duration of the operation and intraoperative core temperature (P<0.001). CONCLUSION The present warming protocol is effective in maintaining perioperative normothermia during major open and laparoscopic urologic procedures.