Hagen Loertzer

Laser-supported partial laparoscopic nephrectomy for renal cell carcinoma without ischaemia time

BackgroundTo date, elective nephron-sparing surgery is an established method for the exstirpation of renal tumors. While open partial nephrectomy remains the reference standard of the management of renal masses, laparoscopic partial nephrectomy (LPN) continues to evolve. Conventional techniques include clamping the renal vessels risking ischaemic damage of the clamped organ. Thus, new techniques are needed that combine a sufficient tissue incision for exstirpation of the tumor with an efficient coagulation to assure haemostasis and abandon renal vessel clamping in LPN. Laser-excision of renal tumors during laparoscopic surgery seems to be a logical solution.MethodsWe performed nephron-sparing surgery without clamping of the renal vessels in 11 patients with a renal tumor in exophytic position (mean size 32 mm, ranging 8–45 mm) by laser-supported LPN.ResultsRegular ultrasound monitoring and insertion of a temporary drainage showed no evidence of postoperative hemorrhage. All tumors were removed with a histopathologically confirmed surrounding margin of normal renal tissue (R0 resection). Serum creatinine, hemoglobin, and hematocrit were nearly unaltered before and after surgery.ConclusionsThe experience won in these patients have confirmed that laser-assisted LPN without clamping of the renal vessels could be a safe and gentle alternative to classic partial nephrectomy in patients with exophytic position of renal tumors.

Occult gastric signet ring cell carcinoma presenting as spermatic cord and testicular metastases: “Krukenberg tumor” in a male patient

Krukenberg tumor is a well-known ovarian metastasis, usually of gastric signet ring cell carcinoma in female patients. Although gastric carcinoma is more frequent in men, to our knowledge, only few cases of counterpart testicular metastases have been described as yet. We report a 64-year-old patient who complained of right testicular pain. Right-sided orchiectomy was performed, and metastatic signet ring cell carcinoma of spermatic cord and testis was diagnosed through histological examination and immunohistochemistry. The following stomach biopsy confirmed the primary signet ring cell carcinoma in the stomach. This extremely rare form of metastatic dissemination resembles the Krukenberg tumor of ovaries. Immunohistochemical staining plays an important role in the differential diagnosis of spermatic cord enlargement.

Chromosomal imbalances in urinary bladder paraganglioma

Paragangliomas are derived from paraganglionic tissue located along the paravertebral and paraaortic axis from skull base to pelvic floor [1]. The most frequent primary sites are the organ of Zuckerkandl (53%), adjacent to the adrenals (26%), the urinary bladder (11%), the mediastinum (5%), and the neck (5%) [2]. Paragangliomas of the urinary bladder comprise less than 10% of paragangliomas and account for only 0.06% of all primary urinary bladder tumors [3]. Differential diagnoses of submucosal urinary bladder tumors include granular cell tumor, solitary fibrous tumor, lipoma, hemangioma, leiomyoma, leiomyosarcoma, rhabdomyosarcoma, neurofibroma, schwannoma, and, very rarely, metastatic tumors, including large cell neuroendocrine carcinoma, lymphoma, andmalignantmelanoma [4,5]. Urinary bladder paragangliomas affect predominantlywomenwith amean age of 45 years and are usually located intramurally in the lateral and posterior wall and the trigone, with an average size of 1.9 cm [3]. Derived from chromaffin cells, these tumors possess the potential to synthesize and secrete catecholamines [1], accounting for some of the leading presenting clinical symptoms, which are painless gross hematuria, paroxysmal hypertension, and micturition attacks, including headache, palpitations, diaphoresis, and blurred vision during or after voiding [4]. Malignancy is estimated at 5e15%, but as in pheochromocytomas, histomorphologic criteria to accurately predict malignancy are still lacking [3]. This is the first reported case of comparative genomic hybridization (CGH) analysis in a paraganglioma of the urinary bladder. At a routine gynecological check-up examination of an asymptomatic 59-year-old female, her transvaginal ultrasound revealed a 2.5-cm protruding mass in the urinary bladder wall. Cystoscopy verified a sharply demarcated submucosal tumor, and histopathologic examination after transurethral resection disclosed a paraganglioma of the urinary bladder. Her medical and family history were uneventful, and familial multiple endocrine neoplasia was ruled out. Abdominal computed tomography (Fig. 1A) and I-MIBG scintigraphy demonstrated a residual tumor in the right lateral urinary bladder wall. Urinary normetanephrines were slightly elevated, with 763.2 mg/d (reference !600 mg/d), but levels of vanillylmandelic acid, dopamine, norepinephrine, and epinephrine were within normal range. Complete resection was achieved by partial cystectomy,

Hereditary papillary renal cell carcinoma primarily diagnosed in a cervical lymph node: a case report of a 30-year-old woman with multiple metastases

BackgroundPapillary renal cell carcinoma is a rare cancer. Some cases can be attributed to individuals with hereditary renal cell carcinomas usually consisting of the clear cell subtype. In addition, two syndromes with hereditary papillary renal cell carcinoma have been described. One is the hereditary leiomyomatosis and renal cell carcinoma, which is characterized by cutaneous and uterine leiomyomas and renal cell carcinoma mostly consisting of the papillary renal cell carcinoma type II with a worse prognosis.Case presentationWe describe a case of a 30-year-old woman with hereditary leiomyomatosis and renal cell carcinoma syndrome with extensively metastasized papillary renal cell carcinoma, primarily diagnosed in a cervical lymph node lacking leiomyomas at any site.ConclusionPapillary renal cell carcinoma in young patients should be further investigated for a hereditary variant like the hereditary leiomyomatosis and renal cell carcinoma even if leiomyomas could not be detected. A detailed histological examination and search for mutations is essential for the survival of patients and relatives.

A three-step technique for umbilicoplasty in a patent urachus.

The concept of ‘ umbilicoplasty ’ emphasises the cosmetic function of the umbilicus as a central structure of the body beyond a simple foetal remnant and focuses on the aesthetic aspects of reconstructive surgery. A protruding umbilicus is considered ‘ unattractive and undesirable ’ by some patients [ 1 ] . Therefore, one aim is to form an inverted umbilicus by resection of the umbilical scarifi cation [ 1 ] . Another aim, especially in female patients, is to form a ‘ scarless ’ and ‘ natural-appearing umbilicus ’ with a ‘ longitudinal deep depression ’ [ 2 ] . Many attempts have been made to establish standardised criteria to defi ne the appearance of an aesthetically pleasing umbilicus. From a study of 147 female participants, it was concluded that the Tor vertically shaped umbilicus with superior hood or shelf is a desirable goal in umbilical reconstruction, as it scored highest in aesthetic appeal [ 2 ] . Beyond cosmetic aspects, the crucial function of the umbilicus to ‘ seal off ’ the abdominal wall from the outer environment has to be restored to avoid urinary discharge and recurrent infections.

Vaginal pelvic repair. Always with mesh or not

ZusammenfassungFür die anatomiegerechte Rekonstruktion des weiblichen Beckenbodens konkurrieren verschiedene operative Verfahren. Der erfahrene Operateur schöpft aus dem Erfahrungsschatz der offenen, laparoskopischen und vaginalen Techniken, welche durch eine unterschiedliche Erfolgs- und Rezidivrate sowie operationsspezifische Komplikationsrisiken gekennzeichnet sind. Im Zuge der Zunahme der Morbidität der Patientinnen besteht der Bedarf nach einer sicheren minimal-invasiven Operationstechnik. Durch die rasante Entwicklung der synthetischen Netze hat sich bei der primären Rekonstruktion des weiblichen Beckenbodens ein unkritischer Einsatz von Fremdmaterial beim vaginalen „Repair“ verbreitet. Dabei ist der vaginale Zugangsweg gegenüber den anderen Operationsverfahren eine weniger invasive Technik mit einer schnellen Rekonvaleszenz, der auch ohne Verwendung von synthetischen Netzen sehr gute Ergebnisse mit einer geringen Komplikations- und Rezidivrate erreicht.AbstractSeveral surgical methods are possible when aiming at reconstruction of pelvic organ prolapse in women, and the experienced surgeon implements the knowledge gained from open, laparoscopic, and vaginal techniques. These feature different rates of success and relapse as well as different complication risks. Because of the accumulating morbidity of aging patients, there is a search for a safe minimally invasive technique. With the advent of synthetic meshes, surgeons have used them frequently and often uncritically for reconstruction of the female pelvic floor. In these cases the vaginal approach is preferred as opposed to alternative techniques, as it is less invasive and allows for better convalescence. Furthermore, this approach leads to low complication and relapse rates even when synthetic meshes are omitted.Several surgical methods are possible when aiming at reconstruction of pelvic organ prolapse in women, and the experienced surgeon implements the knowledge gained from open, laparoscopic, and vaginal techniques. These feature different rates of success and relapse as well as different complication risks. Because of the accumulating morbidity of aging patients, there is a search for a safe minimally invasive technique. With the advent of synthetic meshes, surgeons have used them frequently and often uncritically for reconstruction of the female pelvic floor. In these cases the vaginal approach is preferred as opposed to alternative techniques, as it is less invasive and allows for better convalescence. Furthermore, this approach leads to low complication and relapse rates even when synthetic meshes are omitted.

Synergistic effects of histone deacetylase inhibitor in combination with mTOR inhibitor in the treatment of prostate carcinoma

The aim of this study was to elucidate whether the treatment of a prostate carcinoma cell line (LNCaP) and LNCaP-derived tumors with the histone deacetylase (HDAC) inhibitor valproate in combination with the mammalian target of rapamycin (mTOR) inhibitor temsirolimus resulted in synergistic effects on cell proliferation and tumor growth. LNCaP cells were treated with valproate, temsirolimus or a combination of both. The proliferation rates and the expression of key markers of tumorigenesis were evaluated. In in vivo experiments, LNCaP cells were implanted into immune-suppressed male nude mice. Mice were treated with valproate (per os), temsirolimus (intravenously) or with a combination of both. Tumor volumes were calculated and mRNA expression was quantified. The incubation of LNCaP cells with the combination of valproate and temsirolimus resulted in a decrease of cell proliferation with an additive effect of both drugs in comparison to the single treatment. In particular, the combined application of valproate and temsirolimus led to a significant upregulation of insulin-like growth factor-binding protein-3 (IGFBP-3), which mediates apoptosis and inhibits tumor cell proliferation. In the mouse model, we found no significant differences in tumor growth between the different treatment arms but immunohistological analyses showed that tumors treated with a combination of valproate and temsirolimus, but not with the single drugs alone, exhibited a significant lower proliferation capacity.

Prolapse surgery. With abdominal or vaginal meshes

In prolapse surgery several surgical techniques are available. The different open, laparoscopic and vaginal approaches are distinguished by distinct success and relapse rates and operation-specific complications. A safe and optimal therapeutic pelvic floor surgery should be based on the three support levels according to DeLancy and be individually adjusted for every patient. The vaginal approach may be used for all kinds of female genital prolapse and is a comparatively less invasive technique with a short time of convalescence. Apart from stress incontinence there is no need for synthetic meshes in primary approaches and excellent results with low complication and relapse rates can be achieved. An uncritical application of synthetic material is to be avoided in vaginal repair at all times. Abdominal surgical techniques, both open and laparoscopic, present their strengths in the therapeutic approach to level 1 defects or stress incontinence. They provide excellent functional and anatomical corrections and low relapse rates. Abdominally inserted meshes have lower complication rates than vaginal ones.

Giant umbilical cord edema caused by retrograde micturition through an open patent urachus.

A giant umbilical cord is a rare finding in mature newborns and originates from different developmental etiologies. We report on a case of a mature female newborn presenting a 50 × 8–cm giant umbilical cord without further malformations. Antenatal sonographic findings of a diffuse giant umbilical cord, elevated creatinine levels of 1.3 mg/dL in umbilical cord edema, gross and histopathological findings of allantoic remnants, and umbilical urinary discharge lead to the diagnosis of a patent urachus with retrograde micturition into the umbilical cord. Postnatal surgical repair was required. In antenatal sonography, cystic and diffuse changes should be considered in the differential diagnosis of a giant umbilical cord. In cases of diffuse enlargement, elevated umbilical creatinine can support the diagnosis of a patent urachus with open leakage into the Whartons jelly. Appropriate surgical management is required.

[Laser now also to be used in organ-preserving kidney surgery?].

Kidney surgery is subject to continuous change. Partial nephrectomy is the prevailing method for small and medium-sized tumours and proven to be superior to radical nephrectomy. The conventional technique usually includes clamping the renal vessels. The duration of the ischaemia caused determines the outcome of the remaining renal function. The shorter the ischaemic time the more likely the renal function will be preserved. Thus, new techniques are needed to abandon renal vessel clamping. Essential is a combination of good cutting abilities and assured haemostasis. To date, the commonly used techniques for cutting in partial nephrectomy only partially fulfil these requirements. Establishment of laser in urology offers a new surgical technique that combines both. In spite of the still limited data on laser use in kidney surgery, this method can be assessed favourably. Laser offers a possibility of both open and laparoscopic partial nephrectomy avoiding renal vessel clamping without additional risks or complications.ZusammenfassungDie Nierentumorchirurgie unterliegt einem ständigen Wandel. Als ein Fortschritt in der Therapie von kleineren und mittleren Tumoren der Niere wird heute statt der radikalen Tumornephrektomie, die noch vor einigen Jahren als Standard bei allen Tumoren galt, eine organerhaltende Tumorresektion empfohlen. Die Resektion der Tumoren wird häufig noch unter Ausklemmen der Nierengefäße durchgeführt. Hierbei nimmt man eine warme Ischämie in Kauf. Die Dauer der dabei entstehenden Ischämie ist entscheidend für das Outcome der Nierenrestfunktion. Je kürzer die Ischämiezeit, desto wahrscheinlicher ist eine gute Restfunktion der verbleibende Niere. Daher bedarf es neuer Techniken, die es ermöglichen gänzlich auf ein Ausklemmen der Niere zu verzichten. Diese sollten eine gute Schnittleistung mit einer sicheren Hämostase vereinen. Die bis dato gebräuchlichen Verfahren konnten diese Anforderungen noch nicht hinlänglich erfüllen. Die Etablierung der Lasertechnik in der Urologie ermöglicht nun ein operativ-technisches Verfahren, das eine gute Koagulations- und Schnittleistung in einem verbindet. Die noch spärliche Datenlage zum Einsatz von Laser in der Nierenchirurgie verleiht diesem einen experimentellen Charakter; die bisherigen Ergebnisse sind jedoch durchweg als positiv zu werten. Der Laser bietet sowohl bei der offenen als auch bei der laparoskopischen Nierenteilresektion die Möglichkeit einer sicheren Schnittführung und Hämostase ohne Inkaufnahme zusätzlicher oder vermehrter Komplikationen.AbstractKidney surgery is subject to continuous change. Partial nephrectomy is the prevailing method for small and medium-sized tumours and proven to be superior to radical nephrectomy. The conventional technique usually includes clamping the renal vessels. The duration of the ischaemia caused determines the outcome of the remaining renal function. The shorter the ischaemic time the more likely the renal function will be preserved. Thus, new techniques are needed to abandon renal vessel clamping. Essential is a combination of good cutting abilities and assured haemostasis. To date, the commonly used techniques for cutting in partial nephrectomy only partially fulfil these requirements. Establishment of laser in urology offers a new surgical technique that combines both. In spite of the still limited data on laser use in kidney surgery, this method can be assessed favourably. Laser offers a possibility of both open and laparoscopic partial nephrectomy avoiding renal vessel clamping without additional risks or complications.