Guido Fechner

Surgery for Metastatic Urothelial Carcinoma with Curative Intent: The German Experience (AUO AB 30/05)

BACKGROUND Recent publications suggest a benefit from surgical removal of urothelial carcinoma metastases (UCM) for a subgroup of patients. OBJECTIVE We report the combined experience and outcome of patients undergoing resection of UCM gained at 15 uro-oncologic centers in Germany. DESIGN, SETTING, AND PARTICIPANTS Retrospective survey of 44 patients with distant UCM of the bladder or upper urinary tract who underwent complete resection of all detectable metastases in 15 different German uro-oncological centers between 1991 and 2008. INTERVENTION Resected metastatic sites were the following: retroperitoneal lymph nodes (56.8%), distant lymph nodes (11.3%), lung (18.2%), bone (4.5%), adrenal gland (2.3%), brain (2.3%), small intestine (2.3%), and skin (2.3%). Systemic chemotherapy was administered in 35 of 44 patients (79.5%) before and/or after UCM surgery. MEASUREMENTS Overall, cancer-specific and progression-free survival from time of diagnosis and metastasectomy of UCM. RESULTS AND LIMITATIONS Median survival from initial diagnosis of UCM and subsequent resection was as follows: overall survival, 35 mo and 27 mo; cancer-specific survival, 38 mo and 34 mo; and progression-free survival, 19 mo and 15 mo. Overall 5-yr survival from metastasectomy for the entire cohort was 28%. Seventeen patients were still alive without progression at a median follow-up of 8 mo. Seven patients without disease progression survived for >2 yr and remained free from tumor progression at a median follow-up of 63 mo. No significant prognostic factors could be determined due to the limited patient number. CONCLUSIONS Long-term cancer control and possible cure can be achieved in a subgroup of patients following surgical removal of UCM. Metastasectomy in patients with disseminated UCM remains investigational and should only be offered to those with limited disease as a combined-modality approach with systemic chemotherapy.

Global histone H4K20 trimethylation predicts cancer‐specific survival in patients with muscle‐invasive bladder cancer

Study Type – Prognosis (case series)

Kidney's Nightshift, Kidney's Nightmare? Comparison of Daylight and Nighttime Kidney Transplantation : Impact on Complications and Graft Survival

BACKGROUND Organ distribution and internal procedures often delay kidney transplantation into nighttime. Consequently, surgeons start the operation at a time different from normal working hours, and nighttime work is accompanied by higher incidence of complications. Surgical complications in kidney transplantation often require reoperation, and graft survival can be affected. The aim of our study was to evaluate the impact of the time starting transplantation had on complications and graft survival. METHODS Between 1994 and 2004, a total of 260 patients underwent kidney transplantation. Of these, 166 of 260 (64%) operations were initiated between 8 a.m. and 8 p.m. (day-kidney) and 94 of 260 operations (36%) between 8 p.m. and 8 a.m. (night-kidney). Mean follow-up was 43 months (range, 0-121 months). RESULTS Overall graft failure rate was 8.1% 12 months and 12.7% 60 months after engraftment, respectively. Nighttime operation was associated with a higher risk of graft failure. Twenty-four of 260 patients (9.1%) underwent reoperation within 30 days after transplantation. Reoperation rates (night-kidney: 16 of 94 patients [16.8%], day-kidney: 8 of 166 patients [6.4%]) differed significantly between both groups. Reoperation was associated with risk of graft failure (P < .05, Cox proportional hazard). CONCLUSIONS Nighttime surgery enhances the risk for complications and graft failure. Delaying kidney transplantation of a night-kidney to the following day may be worthwhile, even risking prolonged cold ischemia time.

Thulium laser (Revolix) vapoenucleation of the prostate is a safe procedure in patients with an increased risk of hemorrhage.

Purpose: To evaluate the feasibility and safety of thulium:yttrium-aluminium-garnet laser vapoenucleation of the prostate (ThuVEP) in patients with chronic anticoagulation and bleeding disorders. Methods: We retrospectively analyzed the clinical data (transfusion rate, hemoglobin changes, residual urine, bleeding complications, complications and residual urine) of patients with chronic anticoagulation and bleeding disorders treated with ThuVEP. Anticoagulation was not paused for surgery. Results: We identified 39 patients who fulfilled the inclusion criteria (32 with chronic anticoagulation, 3 with bleeding disorder, and 4 with both). Mean preoperative hemoglobin was 12.9 g/l; the postoperative hemoglobin was 11.7 g/l. One patient received a blood transfusion. Mean residual urine was 166 ml preoperatively and 47 ml postoperatively, respectively; spontaneous voiding postoperatively was feasible in 36 patients. During follow-up, 5 patients suffered from gross hematuria, which was treated conservatively. Conclusions: ThuVEP is a safe procedure in patients with therapeutic anticoagulation, bleeding disorders and platelet aggregation inhibitor medication.

Reducing recurrence and costs in superficial bladder cancer: preclinical evaluation of osmotic cytolysis by distilled water vs. mitomycin

Transurethral resection followed by instillation of chemotherapeutic agents such as mitomycin is considered as standard therapy in recurrent superficial bladder cancer. However, incidence of bladder cancer is increasing, and contrariwise resources to finance the health care systems are decreasing. Therefore, effective alternatives to expensive chemotherapeutics are necessary. Recurrence of bladder cancer after transurethral resection is mostly promoted by reimplantation of dissolved tumour cells which are therapeutical purpose of any intravesically instillated agent.

Continent ileovesicostomy after bladder neck closure as salvage procedure for intractable incontinence.

Introduction We evaluated the success rate of continent vesicostomy using an ileal segment with seroserosally embedded, tapered ileum for bladder augmentation with continent stoma following bladder neck closure (BNC) for severely damaged bladders or persistent urinary incontinence. Material and methods A total of 15 patients were treated for persistent urinary incontinence or non–reconstructible bladder outlet between 2003 and 2012. Underlying diagnosis included post–prostatectomy incontinence (n = 5), recurrent bladder neck stenosis (n = 5), neurogenic bladder (n = 3), urethral tumor recurrence following orthotopic neobladder (n = 1) and post–TVT and colposuspension incontinence (n = 1). All patients underwent open BNC, omental interposition and continent vesicoileostomy. The continent outlet was placed in the lower abdomen using a circumferential subcutaneous and skin plasty to avoid retraction. Data collected included age, underlying diagnosis, stoma site, time to complications and need for subsequent surgical revisions. All patients received a standardized questionnaire at the time of data acquisition and were personally interviewed. Results Median follow–up was 24 months (range: 2–111). Primary BNC was successful in all patients and primary continence rate was 86.7%. Two patients (13.3%) suffered from failure of the continence mechanism, caused by stoma stenosis at skin level and insufficiency of the bladder augmentation and stoma due to local infection. One additional patient developed a mild stomal incontinence without need for further reconstruction. Regardless of the number of revisions, at the last follow–up 93.3% of patients had a functional channel. All complications occurred within the first postoperative year. Conclusions This technique is an effective last resort treatment for patients with non–reconstructible bladder outlet.

Modified Spectrometry (O2C Device) of Intraoperative Microperfusion Predicts Organ Function After Kidney Transplantation: A Pilot Study

BACKGROUND Delayed graft function (DGF) is defined as posttransplantation dialysis within 1 week, which might be associated with impaired long-term graft survival. The aim of our pilot study was to establish the ability of intraoperative spectrometry of allograft microperfusion to predict DGF. METHODS Twenty human kidney allografts transplanted from deceased donors were evaluated intraoperatively after reperfusion using modified organ spectrometry (O2C device). We examined hemoglobin oxygen saturation, intravascular amount of hemoglobin, and microperfusion flow/velocity. RESULTS Retrospectively, 10/20 (50%) allografts with measurable impairment of cortical hemoglobin oxygen saturation and microperfusion flow/velocity developed DGF. Retrospectively, we found that if the intravascular amount of hemoglobin was increased upon intraoperative measurement, the kidney was prone to develop DGF. CONCLUSIONS Spectrometry data predicted DGF. Our results supported the thesis that impaired microperfusion is the key to DGF and might be related to postcapillary endothelial damage or intravascular sludge.

Evoluting the Invaginated – One Step Closer to the Perfect Valve Modified Serosal Lined Tapered Ileum (Kälble’s Procedure) as a Continence Mechanism for Catheterizable Pouches

Introduction: A sufficient and easily catheterizable continence mechanism is essential in continent cutaneous pouches. Kälble embedded a tapered ileum as efferent segment into a serosal lined tunnel formed by an ileal ‘U’ according to the principle of Abol-Enein and Ghoneim. We report a modified technique applied in a series of 12 patients who had undergone different urinary diversions. Methods: All patients received a modified Kälble procedure (first-line urinary diversion, n = 8; revision/undiversion, n = 4) for different forms of continent pouches. To alleviate embedding of the efferent segment, ileal detubularization was performed asymmetrically. Mean follow-up was 9.5 months. Results: All patients were continent and performed self-catheterization easily. Of 12 patients, 2 underwent endoscopic incision for stomal stenosis 8 and 12 months postoperatively. Conclusions: Subject to our short follow-up, Kälble’s technique is a promising alternative in patients undergoing a continent cutaneous urinary diversion but offers an inapplicable or missing appendix.

Spindle cell rhabdomyosarcoma of the prostate

The spindle cell rhabdomyosarcoma is a rare variant of the embryonal rhabdomyosarcoma, mostly occurring in childhood. Only a few cases are described in adults. To date, no case of the spindle cell subtype of the prostatic embryonal rhabdomyosarcoma has been published. We report on a 23‐year‐old man, initially presenting with obstructive micturition problems, perineal pain and night sweat. After diagnosis by transrectal biopsy of the prostate, radiochemotherapy within the CWS 2002 P study was applied: nine cycles of vincristine, doxorubicin, actinomycin D, ifosfamide, and fractionated radiotherapy of the tumor and suspect lymph nodes (final dose 50.4 Gy). The tumor initially shrank, but an early local recurrence arose. Second‐line chemotherapy was applied, followed by a salvage radical cytoprostatectomy. The patient died of disseminated disease 14 months after diagnosis.

The Role of Superselective Transcatheter Arterial Embolisation in Management of Complications after Kidney Surgery

PURPOSE Transcatheter arterial embolisation (TAE) is replacing open procedures in terms of vascular malformations or traumatic haemorrhage. Furthermore, the role of TAE is established in post-surgery bleeding complications. We report on a number of patients with severe haemorrhage after kidney surgery and successful management by TAE. MATERIALS AND METHODS Gross renal haemorrhage was observed after pyelocalicolithotomy and open kidney-sparing surgery. One patient developed a large arteriovenous fistula after kidney transplantation preceded by open biopsy. Technique of TAE: In all cases the bleeding vessel was located by transfemoral arteriography. Embolisation was performed by dropping platinum coils or gelfoam pellets. RESULTS TAE stopped the haemorrhage in all patients and occluded the arteriovenous fistula in the renal allograft. No complications were observed. CONCLUSION TAE can be considered as the treatment of choice for a widespread range of complications after kidney surgery. It should always be taken into consideration before open surgical revision.