Hansjörg Danuser

Radical Cystectomy for Bladder Cancer Today—A Homogeneous Series Without Neoadjuvant Therapy

PURPOSE To investigate the effect of pelvic lymph node dissection and radical cystectomy for transitional cell cancer of the bladder on recurrence-free and overall survival, pelvic recurrences, and metastatic patterns in a homogeneous group. PATIENTS AND METHODS A consecutive series of patients undergoing pelvic lymphadenectomy and radical cystectomy between 1985 and 2000 was analyzed. All patients were staged N0, M0 preoperatively, and no patient received neoadjuvant radio/chemotherapy. Pathologic characteristics based on the 1997 tumor-node-metastasis system, recurrence-free/overall survival, and metastatic patterns were determined. RESULTS Five hundred seven patients (age 66 +/- 12 years) with a mean follow-up time of 45 months (range, 0.1 to 176 months) were analyzed. Five-year recurrence-free and overall survival were, respectively, 73% and 62% for patients with organ-confined, lymph node-negative tumors (n = 217; < or = pT2, pN0) and 56% and 49% for non-organ-confined, lymph node-negative tumors (n = 166; > pT2, pN0). Positive lymph nodes were found in 124 (24%) patients who had a 5-year recurrence-free (33%) or overall (26%) survival. Isolated local recurrences were observed in 3% of patients with organ-confined tumors (< or = pT2, pN0), 11% with non-organ-confined tumors (> pT2, pN0), and 13% with positive lymph nodes (any pT, pN+). Distant metastases developed in 25% of patients with organ-confined tumors, 37% with non-organ-confined tumors, and 51% with positive lymph nodes. CONCLUSION Despite negative preoperative staging, pelvic lymphadenectomy and cystectomy for bladder cancer reveal a high percentage of unsuspected nodal metastases (24%) that have a 25% chance for long-term survival. This procedure also ensures a low pelvic recurrence rate even in lymph node-positive patients, and patients with locally advanced cancer have a 56% probability of 5-year recurrence-free survival.

Positioning Injury, Rhabdomyolysis, and Serum Creatine Kinase-Concentration Course in Patients Undergoing Robot-Assisted Radical Prostatectomy and Extended Pelvic Lymph Node Dissection

BACKGROUND AND PURPOSE During robot-assisted radical prostatectomy (RARP), patients remain in a steep Trendelenburg position. This can cause positioning injuries as well as rhabdomyolysis. The primary diagnostic indicator of rhabdomyolysis is elevated serum creatine kinase (CK). We investigate whether RARP with extended pelvic lymph node dissection (ePLND) in a prolonged extreme Trendelenburg position can cause positioning injuries and rhabdomyolysis. PATIENTS AND METHODS We performed a prospective study of the first 60 patients undergoing RARP and ePLND for organ-confined prostate cancer at our institute. Positioning injuries were graded according to three degrees of clinical severity. Serum-CK, serum-pH, and base excess (BE) were measured before, during, and for 5 days after surgery. Rhabdomyolysis was defined by serum-CK levels >5000 IU/L. RESULTS Median operative time was 317 minutes (range 200-475 min); median time in the Trendelenburg position was 282 minutes (range 170-470 min). Serum-CK was significantly elevated 6 hours postoperatively, peaking at 18 hours postoperatively. Serum-CK levels did not correlate with pH, BE, and perioperative creatinine values. Serum-CK course shows weak correlation with body mass index (BMI), operative time, Trendelenburg position time, and medium correlation with positioning injuries of any degree. Twenty-one of the 60 (35%) patients showed positioning-related injuries: 16 (27%) patients degree I, 2 (3%) patients degree II, and 3 (5%) patients degree III. Rhabdomyolysis developed in 10 patients. Postoperative renal failure did not develop in any patient receiving postoperative hypervolemic diuretic therapy nor any patient with injuries degrees I, II, or III. conclusion: Clinically relevant positioning injuries and rhabdomyolysis can occur in patients who are subjected to prolonged extreme Trendelenburg position during RARP and ePLND, especially at the beginning of the learning curve. Serum-CK increases significantly after surgery, peaking 18 hours postoperatively. Serum-CK elevation alone is not predictive of positioning injury. By very long operative and Trendelenburg times as well as high BMI with visible position injuries, we recommend serum-CK measurement 6 and 18 hours postoperatively followed by hypervolemic therapy to prevent possible renal injury from rhabdomyolysis if serum-CK >5000 IU/L.

Experience in 100 Patients with an Ileal Low Pressure Bladder Substitute Combined with an Afferent Tubular Isoperistaltic Segment

Between April 1985 and April 1993, 100 consecutive men underwent lower urinary tract reconstruction after cystectomy. An ileal low pressure reservoir using the Goodwin cup-patch principle was combined with an afferent ileal tubular segment. The early complication rate was 11%, including 2 postoperative deaths due to septicemia. After a median followup of 27 months (range 3 to 96) 14 patients required surgery for late complications (intestinal obstruction, urethral stricture or tumor recurrence, hernia or ureteral stenosis). A total of 32 patients died of metastatic bladder cancer and 7 died of other causes. The functional capacity of the bladder substitute was increased to the desired 450 to 500 ml. after 3 to 12 months, which was paralleled by improving urinary continence. After 1 year 92% of the patients were continent by day and after 2 years 80% were continent at night. Upper tract surveillance with excretory urography, renal ultrasound and serum creatinine estimation has shown 4 left ureteral strictures but not significant upper tract deterioration or ureteral recurrence. Significant reflux was not observed during video urodynamics unless the reservoir was overfilled. During voiding, by outlet relaxation and straining if necessary, the intra-abdominal pressure increase with straining acted equally on the reservoir and ureters. Therefore, unlike voiding with a normal bladder, no isolated intravesical pressure increase occurred and, thus, there was no reflux from the reservoir. The combination of an ileal low pressure reservoir with an afferent isoperistaltic ileal segment and an open end-to-side ureteroileal anastomosis allows for radical cancer surgery with resection of the ureters where they cross the iliac vessels and minimizes the risk of ureteral stenosis. The unidirectional peristalsis of the ureters and the afferent tubular ileal segment seem to protect the upper urinary tract sufficiently. The surgical technique is straightforward and allows for later conversion to an ileal conduit if necessary. The functional results of the bladder substitute are comparable to other similar reservoir techniques, provided that the patients are carefully selected, well rehabilitated and meticulously followed.

Antireflux Nipples or Afferent Tubular Segments in 70 Patients with Ileal Low Pressure Bladder Substitutes: Long-term Results of a Prospective Randomized Trial

PURPOSE Intestinal low pressure orthotopic bladder substitutes have no major coordinated contractions during micturition. Therefore, the importance and type of reflux prevention were assessed in a prospective randomized study. MATERIALS AND METHODS A total of 70 patients with an ileal low pressure bladder substitute was randomized to receive a nipple valve or an isoperistaltic afferent ileal tubular segment for reflux prevention. RESULTS After median observation times of 57 and 45 months, respectively, the results regarding functional reservoir capacity, incidence of infected urine, urinary continence, voiding habits and serum electrolytes, urea and creatinine were similar in both groups. Severe upper tract dilatation due to ureteroileal or nipple stenosis occurred in 9 of 67 evaluable reno-ureteral units (13.5%) in patients with antireflux nipples and in 2 of 69 (3%) in patients with an afferent tubular segment. This difference in favor of the latter cases is significant (Fishers exact test p < 0.03). Video urodynamics did not show reflux of contrast medium during voiding in either group. A simultaneous intravesical, intra-abdominal and intrapelvic pressure increase was noted during the Valsalva maneuver. CONCLUSIONS While long-term upper tract preservation by an afferent tubular ileal segment must be confirmed in larger patient series with longer followup, our results indicate that reflux prevention in patients with orthotopic low pressure bladder substitutes is not a major concern and does not justify the use of antireflux mechanisms with a high complication rate.

A Prospective Trial Comparing Consecutive Series of Open Retropubic and Robot-Assisted Laparoscopic Radical Prostatectomy in a Centre with a Limited Caseload

BACKGROUND Robot-assisted radical prostatectomy (RALP) is performed worldwide, even in institutions with limited caseloads. However, although the results of large RALP series are available, oncologic and functional outcomes as well as complications from low-caseload centres are lacking. OBJECTIVE To compare perioperative, oncologic, and functional outcomes from two consecutive series of patients with localised prostate cancer treated by retropubic radical prostatectomy (RRP) or recently established RALP in our hospital, which has a limited caseload. DESIGN, SETTING, AND PARTICIPANTS One hundred fifty consecutive patients were enrolled. Their data and outcomes were collected and extensively evaluated. INTERVENTION Seventy-five consecutive patients underwent RRP, and 75 consecutive patients underwent RALP, including all patients of the learning curve. MEASUREMENTS Patient baseline characteristics, perioperative and postoperative outcomes, and complications were evaluated. End points were oncologic data (positive margins, prostate-specific antigen [PSA]), perioperative complications, urinary continence, and erectile function at 3- and 12-mo follow-up. RESULTS AND LIMITATIONS The preoperative parameters from the two groups were comparable. The positive surgical margin (PSM) rates were 32% for RRP and 16% for RALP (p=0.002). For RRP and RALP, the PSA value was <0.2 ng/ml in 91% and 88% of patients 3 mo postoperatively (p=0.708) and in 87% and 89% of patients 12 mo postoperatively (p=0.36), respectively. Continence rates for RRP and RALP were 83% and 95% at 3-mo follow-up (p=0.003) and 80% and 89% after 12-mo follow-up (p=0.092), respectively. Among patients who were potent without phosphodiesterase type 5 inhibitors (PDE5-I) before RRP and RALP, recovery of erectile function with and without PDE5-Is was achieved in 25% (12 of 49 patients) and 68% (25 of 37 patients) 3 mo postoperatively (p=0.009) and in 26% (12 of 47 patients) and 55% (12 of 22 patients) 12 mo postoperatively (p=0.009), respectively. Minimal follow-up for RRP was 12 mo; median follow-up for the RALP group was 12 mo (range: 3-12). According to the modified Clavien system, major complication rates for RRP and RALP were 28% and 7% (p=0.025), respectively; minor complication rates were 24% and 35% (p=0.744), respectively. CONCLUSIONS Despite a limited caseload and including the learning curve, RALP offers slightly better results than RRP in terms of PSM, major complications, urinary continence, and erectile function.

ENDOPYELOTOMY FOR PRIMARY URETEROPELVIC JUNCTION OBSTRUCTION: RISK FACTORS DETERMINE THE SUCCESS RATE

PURPOSE We prospectively assessed the feasibility, complications, and short-term and long-term results of endopyelotomy for primary ureteropelvic junction obstruction. MATERIALS AND METHODS In 80 consecutive patients primary ureteropelvic junction obstruction was diagnosed by excretory urogram or nephrostomogram, retrograde pyelography, diuresis renography and the Whitaker test in ambiguous cases. In all patients antegrade endopyelotomy was performed with a cold knife and an indwelling stent was left for 6 weeks. At 6 and 24 months postoperatively results were assessed clinically by an excretory urogram and/or diuretic renography and later by questionnaire and ultrasound. RESULTS The primary success rate was 89% (71 of 80 patients) after the first endopyelotomy and increased to 91% (73 of 80 patients) after 2 patients had a second endopyelotomy. After median followup of 26 months (range 1.5 to 72) 6 of the 73 initially successfully treated patients had relapse. Two were successfully re-treated by a second endopyelotomy, resulting in an overall success rate of 81% (65 of 80 patients) after 1 procedure and 86% (69 of 80 patients) after a second endopyelotomy in 4 patients. Mean preoperative pyelocaliceal volume decreased from 64 +/- 33 to 41 +/- 20 ml. (p = 0.0003) 6 months after endopyelotomy and did not change during the following 18 months. The probability of successful endopyelotomy was better in patients with a preoperative pyelocaliceal volume less than 50 ml. (87%) and worse in patients with a volume greater than 50 ml. (76%). A crossing vessel to the lower pole of the kidney causing persistent functional obstruction of the ureteropelvic junction was found in 6 of the 10 patients re-treated by open pyeloplasty (9) or nephrectomy (1). Preoperative mean renal function as determined by diuretic renography was significantly lower in patients with failed endopyelotomy than in successfully treated patients. Successfully treated patients showed no change in renal function 6 and 24 months postoperatively. CONCLUSIONS Endopyelotomy in primary ureteropelvic junction obstruction is a safe, minimally invasive procedure with a high primary success rate and a low relapse rate. Open pyeloplasty could be avoided in 86% of our patients. Endopyelotomy is less invasive, has less functional and esthetic sequelae than open pyeloplasty and does not compromise open surgery if that becomes necessary. We recommend endopyelotomy as first line treatment for patients with primary ureteropelvic junction obstruction.

A Prospective Randomized Trial Comparing 2 Lithotriptors for Stone Disintegration and Induced Renal Trauma

PURPOSE We compare the efficacy and resulting kidney trauma of the HM3 (Dornier Medical Systems, Inc., Marietta, Georgia) and Lithostar Plus (Siemens, Issaquah, Washington) lithotriptors in a prospective randomized trial treating calix and renal pelvis stones. MATERIALS AND METHODS Patients with a solitary renal pelvic stone 2 cm. or less in diameter or a solitary calix stone 1 cm. or less in diameter were randomized for treatment with the HM3 or Lithostar Plus. Stone disintegration and dilatation of the pyelocaliceal system were evaluated by abdominal plain x-ray and renal ultrasound 1 day and 3 months after treatment. Kidney trauma was determined by measurement of N-acetyl-beta-glucosaminidase and beta-galactosidase (NAG) in pretreatment urine and 4, 12-hour urine samples collected within the first 2 days after extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc.). RESULTS Of 167 patients with 176 stones 91 were randomized to the HM3 and 85 to the Lithostar Plus lithotriptor group. The preoperative stone burden was comparable in both groups. On postoperative day 1 patients treated with the HM3 or Lithostar Plus were stone-free or had fragments 2 mm. or less (91% and 65%, p <0.001), 3 to 5 mm. (8% and 25%, p = 0.003) and 6 mm. or greater (1% and 10%, p = 0.008), respectively. Patients treated with the HM3 had less posttreatment dilatation of the collecting system (p = 0.01). Obstructive pyelonephritis occurred in 1% of the HM3 and 8% of the Lithostar Plus group (p = 0.02). Re-treatment rate was 4% in the HM3 and 13% in the Lithostar Plus group (p = 0.05). Mean excretion of urinary NAG per treatment (including re-treatments) was comparable in both groups but NAG excretion in relation to stone volume and shock wave number 12 to 24 hours after ESWL was significantly higher in the HM3 group (p <0.05). At 3-months postoperatively 89% of the patients treated with the HM3 and 87% treated with the Lithostar plus were stone-free with no dilatation of the collecting system. CONCLUSIONS This prospectively randomized study indicated that the HM3 is still the gold standard in regard to disintegration of pelvicaliceal stones. Stone disintegration with the HM3 is better with fewer shock waves, re-treatment rate is lower, and posttreatment dilatation of the collecting system and complications such as obstructive pyelonephritis are less than those with the Lithostar Plus. ESWL induced kidney trauma is minor and resolves within 2 days. The HM3 delivers more energy per shock wave into the kidney as assessed by urinary NAG.

Ultrasound Assessment of Detrusor Thickness in Men—Can it Predict Bladder Outlet Obstruction and Replace Pressure Flow Study?

PURPOSE We estimated the diagnostic accuracy of ultrasound detrusor thickness measurement for BOO and investigated whether this method can replace PFS for the diagnosis of BOO in some patients with lower urinary tract symptoms. MATERIALS AND METHODS Detrusor thickness was measured by linear ultrasound (7.5 MHz) at a filling volume of greater than 50% of cystometric capacity in 102 men undergoing PFS for LUTS. All patients with prior treatment for bladder outlet obstruction and those with underlying neurological disorders were excluded from analysis. Detrusor thickness was correlated with PFS data. Obstruction was defined according to the Abrams-Griffiths nomogram. RESULTS Detrusor thickness was significantly higher (p <0.0001) in obstructed (61 cases, median detrusor thickness 2.7 mm, IQR 2.4 to 3.3) compared to unobstructed (18 cases, median detrusor thickness 1.7 mm, IQR 1.5 to 2) as well as equivocal (23 cases, median detrusor thickness 1.8 mm, IQR 1.5 to 2.2) cases. A weak to medium Spearman correlation was found between detrusor thickness and PFS parameters. For a diagnosis of BOO, detrusor thickness of 2.9 mm or greater had a positive predictive value of 100%, a negative predictive value of 54%, specificity of 100% and sensitivity of 43%. ROC analysis revealed that detrusor thickness had a high predictive value for BOO with an AUC of 0.88 (95% CI 0.81-0.94). CONCLUSIONS In men with LUTS without prior treatment and/or neurological disorders, ultrasonographically assessed detrusor thickness 2.9 mm or greater has a high predictive value for BOO and can replace PFS for the diagnosis of BOO. However, this cutoff value needs to be validated in a larger study population.

No evidence of osteopenia 5 to 8 years after ileal orthotopic bladder substitution

PURPOSE The use of bowel segments as bladder substitutes may result in chronic, impaired vitamin D and calcium metabolism, and ultimately in bone demineralization. MATERIALS AND METHODS Bone metabolism was examined in 14 patients who lived for 5 to 8 years with an ileal low pressure bladder substitute after radical cystectomy for bladder cancer. Bone mineral density was measured using dual energy x-ray absorptiometry of the total skeleton, lumbar spine, femoral neck, and tibial epiphysis and diaphysis. Laboratory studies included serum levels of 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D, intact parathyroid hormone, plasma alkaline phosphatase, electrolytes, creatinine and blood gas analysis. RESULTS Bone mineral density was normal in all patients. There was no evidence of deficient vitamin D stores. There was a tendency toward slightly elevated serum creatinine values in patients with preexisting impaired renal function, including 1 who also had slight acidosis. No patient had hyperchloremia. CONCLUSIONS We found no evidence of osteomalacia, osteoporosis or significant metabolic acidosis in 14 patients with an ileal bladder substitute for 5 to 8 years. However, it is not known whether the absence of osteopenia would also apply to patients with poor renal function, to those not followed meticulously and, thus, at risk for major long-term functional or metabolic disturbances from the ileal bladder substitute or to patients with orthotopic bladder substitutes made from longer or other bowel segments than we used.

Extracorporeal shock wave lithotripsy in situ or after push-up for upper ureteral calculi : a prospective randomized trial

A total of 110 patients with upper ureteral calculi was admitted to a prospective trial and randomly allocated to 2 groups: 1 group treated with in situ extracorporeal shock wave lithotripsy (ESWL) and 1 group treated with ureteral manipulation before ESWL. All patients had solitary upper ureteral calculi without urinary infection. The stones had to be smaller than 1 cm. and located more than 2 cm. lateral to the spine. ESWL was performed with the Dornier HM3 lithotriptor. One patient in the in situ ESWL group had to be treated twice because disintegration of the stone was insufficient after the initial treatment session. All other patients underwent only 1 treatment session. Because 16 patients were lost to followup, 94 were evaluable for the analysis of immediate and long-term results. For disintegration of the stones in situ ESWL needed significantly more shock waves (1,844 +/- 639 versus 1,297 +/- 473, p < 0.001) and a higher voltage (19.5 +/- 1.4 versus 18.7 +/- 0.9 kv., p < 0.001). There were no severe complications in either treatment group. At 3 months 44 of 46 patients (96%) after in situ ESWL and 45 of 48 (94%) after ureteral manipulation before ESWL were free of stones. In view of these results it is suggested that uncomplicated upper ureteral calculi (as defined previously) should be treated first with in situ ESWL, thus, avoiding an invasive procedure.