Jaroslav Pacovsky

Long-term survival after radical surgery for renal cell carcinoma with tumour thrombus extension into the right atrium.

Whats known on the subject? and What does the study add?

Bipolar Transurethral Resection of Anastomotic Strictures After Radical Prostatectomy

PURPOSE The efficacy of the bipolar endoscopic resection for anastomotic stricture was assessed and compared with holmium laser treatment. PATIENTS AND METHODS We studied a cohort of 39 patients with anastomotic strictures in years 1999 to 2007. Twenty-two patients had undergone bipolar resection, and 17 patients had undergone holmium laser treatment. The mean age of the bipolar cohort was 63.8 years; initial prostate-specific antigen (PSA) level was 10.7 ng/mL. The mean age of the laser cohort was 64 years; initial PSA level was 7.8 ng/mL. The results were evaluated by measurement of the maximum urinary flow (Qmax) and the postvoid residual volume of urine (PVR) before surgery, and at 6 weeks and 6 months after surgery. The Wilcoxon rank-sum test was used for statistical analysis, and a P value <0.05 was considered significant. RESULTS The mean follow-up period was 42 (14-74) months. Improvements in Qmax and PVR were recorded in the two cohorts. In the bipolar cohort, the mean values of Qmax were 3.9 mL/s, 14 mL/s, and 13 ml/s, while PVR values were 46 mL, 10 mL, and 11 mL. The mean values of Qmax in the laser cohort were 3.7 mL/s, 11 mL/s and 6.1 mL/s; PVR were 25 mL, 16 mL, and 19 mL. Statistically significantly better results of Qmax over 6 months were in the bipolar cohort (P < 0.001). No perioperative complications and no deterioration of urinary continence were recorded. CONCLUSION The bipolar resection of an anastomotic stricture is a highly effective method that produces better long-term results than the holmium laser treatment.

Radical prostatectomy in high-grade prostate cancer, salvage and adjuvant radiotherapy.

Introduction: Prostate cancer with a Gleason score (GS) of 8–10 is linked to a higher risk of recurrence and progression. The aim of this paper is to evaluate treatment results of our high-risk patient cohort.Patients and Methods: The cohort of 42 patients with radical prostatectomy (RP) specimen histology GS 8–10 was assessed. The patients were followed up after RP and radiotherapy (RT) was delivered in case of a biochemical relapse. Adjuvant radiotherapy (aRT) was delivered only in case of a positive surgical margin (PSM). The following parameters were evaluated: biochemical progression-free survival (BPFS), overall survival (OS) and cancer-specific survival (CSS). The second objective was to evaluate adverse effects of RP and RT. Results: The median follow-up time was 88 months (18–168). RP led to BPFS in 16 patients (38%). Five patients with PSM underwent aRT and 20 underwent salvage radiotherapy (sRT). One patient died of myocardial infarction and 1 patient died of metastatic disease. Skeletal metastases were recorded in 2 patients. The BPFS in RP combinations with sRT or aRT was reached in 29 patients (69%). The OS and CSS in our cohort reached 95 and 98%, respectively. Conclusion: Management with aRT only in PSM was very effective, according to our retrospective study.

The estimation of post-transplant lymphocele origin using creatine kinase activity

Abstract Introduction. The aim of this research was to create a laboratory instrument for the estimation of post-transplant lymphocele origin. It is based on the enzymatic activity of creatine kinase (CK) in the lymphocele content. Material and methods. A total of 120 lymph samples from different retroperitoneal regions were obtained from non-transplanted patients; equal numbers from the iliac region, renal cysts, and the subdiaphragmatic retroperitoneum. Activities of creatine kinase (CK) and γ-glutamyl transpeptidase (GGT) were determined in all samples and statistically analyzed against their activity in serum from patients without surgery. Results. Activities of CK in the pelvis, retroperitoneum, renal cysts, and serum were 5.06, 0.83, 6.48 (P < 0.001), 2.50, 0.73, 3.60 (P < 0.001), 0.02, 0.01, 0.05 (P < 0.001), and 0.66, 0.41, 0.79 μkat/l, respectively. Activities of GGT in the same lymph samples were 0.26, 0.16, 0.36 (P = 0.048), 0.41, 0.25, 0.48 (non-significant), 0.11, 0.07, 1.17 (P = 0.003) and 0.34, 0.24, 0.55 μkat/l, respectively. A graph was constructed relating CK activity to lymph origin. Conclusion. Significantly different CK enzyme activity was observed in different regions of the retroperitoneum. The presented graph is a simple instrument for the estimation of the lymphocele content origin. The method requires percutaneous aspiration of the lymphocele and evaluation of the CK and GGT activity in the sample. From the graph the estimated proportion of renal lymph in the lymphocele can be read directly. This instrument can provide better understanding of post-transplant lymphocele fluid source.

Urological surgery in elderly patients: results and complications

Purpose Owing to the large aging population, a growing number of elderly patients are undergoing surgical treatment. Surgical procedures in elderly patients are associated with a higher risk of complications. The aim of this study was to evaluate the efficacy and safety of urological surgeries in old patients. Methods The authors carried out a retrospective study, evaluating results and early postoperative complications in patients aged 75 years and older. The cohort of patients included 221 patients who underwent surgical procedures in the department of urology between January 2011 and December 2012. The average age of patients was 78. The results and complications were categorized based on the type of surgery performed, and the Dindo–Clavien scale. Results The median follow-up was 18 months. All surgeries for malignant tumors were performed successfully with no residual disease. Totally, 48 (22%) complications were recorded. The most serious were as follows: one patient (<0.5%) died; and four (<2%) patients underwent reoperation. The most common complications involved infection, mainly sepsis and surgical site infections. Other complications included mild respiratory insufficiency, delirium, bleeding, etc. Conclusion Surgeries in elderly patients were effective and safe. The cornerstone of safety is careful preparation and treatment of comorbidities. Complications occurred mainly as a result of emergency procedures during emergency procedures and in major surgeries such as cystectomy and nephrectomy. The standard use of low molecular-weight heparin caused no incidence of thromboembolic disease.

The Taguchi Technique of the Transplanted Kidney Ureter Implantation – Single Centre Experience

Taguchi technique of ureteral implantation was used in 22 kidney transplant patients (group T). Group T was compared with 25 patients who were treated using Lich-Gregoir technique (group LG). Immunosuppression, incidence of biopsy evidenced acute cellular rejection (ACR), haematuria rate and ureteral complications (stricture, reflux) were assessed in both groups. The immunosuppression used was based on cyclosporin A (63.6%), tacrolimus (27.3%) and sirolimus (8.1%) in T group. Cyclosporin A (72%), tacrolimus (20%) and sirolimus (8%) were used in LG group. No induction was used. The incidence of ACR was similar in both groups – T resp. LG was 50% resp. 52%. Haematuria after operation was on average 4.0 days in the T group and on average 3.1 in the LG group. Ureteral complications were observed in 18.2% of cases in T group and in 16% of cases in LG group. No reflux was evidenced in any group. Taguchi technique is fast and very easy to do. A slightly higher incidence of ureteral complications and a longer period of postoperative haematuria were observed in T group. Taguchi technique is very easily performed with a shorter operating time. We advocate it as a method of ureteral implantation on the thin-wall urinary bladder. The results were very good in these cases.

Methylation status as a predictor of intravesical Bacillus Calmette-Guérin (BCG) immunotherapy response of high grade non-muscle invasive bladder tumor

BACKGROUND AND AIMS Genetic and epigenetic alterations play an important role in urothelial cancer pathogenesis. Deeper understanding of these processes could help us achieve better diagnosis and management of this life-threatening disease. The aim of this research was to evaluate the methylation status of selected tumor suppressor genes for predicting BCG response in patients with high grade non-muscle-invasive bladder tumor (NMIBC). MATERIALS AND METHODS We retrospectively evaluated 82 patients with high grade non-muscle-invasive bladder tumor (stage Ta, T1, CIS) who had undergone BCG instillation therapy. We compared epigenetic methylation status in BCG-responsive and BCG-failure groups. We used the MS-MLPA (Methylation-Specific Multiplex Ligation-Dependent Probe Amplification probe sets ME001 and ME004. The control group was 13 specimens of normal urotel (bladder tissue)). RESULTS Newly identified methylations in high grade NMIBC were found in MUS81a, NTRK1 and PCCA. The methylation status of CDKN2B (P=0.00312**) and MUS81a (P=0.0191*) is associated with clinical outcomes of BCG instillation therapy response. CDKN2B and MUS81a unmethylation was found in BCG failure patients. CONCLUSION The results show that the methylation status of selected tumor suppressor genes (TSGs) has the potential for predicting BCG response in patients with NMIBC high grade tumors. Tumor suppressor genes such as CDKN2b, MUS81a, PFM-1, MSH6 and THBS1 are very promising for future research.

Endoscopic treatment of a rectovesical fistula following radical prostatectomy by over-the-scope clip (OTSC)

The successful management of a rectovesical fistula after radical prostatectomy is difficult. Minimally invasive treatment by over-the-scope clip (OTSC) is a novel method. The authors present results with the use of OTSC. This method was used in 2 patients. The first patient had a rectovesical fistula detected on the fifth day after a prostatectomy. The second patient experienced rectal perforation during prostatectomy and a recurrent fistula after fistulorrhaphy. Both patients had a small fistula located in the vesicourethral anastomosis. Both patients underwent endoscopic OTSC placement. The median follow-up was 26 months. The success rate was 50%. The first patient healed successfully and the second patient had a relapse. The York-Mason procedure was eventually successful. According to our initial experience, the OTSC is suitable for small fistulas detected shortly after a prostatectomy. A more complex fistula, though small, carries a higher recurrence risk.

Percutaneous radiofrequency and microwave ablation in the treatment of renal tumors – 10 years of experience

Introduction The standard radical treatment of renal cell carcinoma is surgical resection, but it is not suitable for patients with serious medical comorbidities and solitary kidney tumors. Minimally invasive ablation techniques could be an appropriate therapeutic alternative. Aim To retrospectively evaluate the technical success, mid-term and long-term efficacy and safety of radiofrequency and microwave ablation in patients with small renal tumors. Material and methods Over the course of 10 years, 91 ablation procedures in 64 patients for 68 tumors, of size 12–60 mm, were performed using only conscious sedation. These ablations were done under the guidance of computed tomography. We treated 41 males and 23 females with solitary kidney tumors (14 cases) and tumors in non-surgical candidates (54 cases). Results In 50 (73.5%) tumors single treatment was successful; in 13 (19.1%) cases a second procedure was used successfully, and in the 5 largest tumors (sizes 45–60 mm, 7.4%) a third treatment was necessary. Within the follow-up 10 (15.6%) patients died, but none due to metastatic renal cell carcinoma. Only 1 serious complication was observed – retroperitoneal and psoatic hematoma. Early recurrence occurred in 18 (26.5%) tumors. Late recurrence was detected in 5 (7.4%) cases. In all cases complete local control of the renal tumors was reached. Conclusions Percutaneous ablation is a very effective treatment for patients with small renal tumors of the T1a group with a minimal complication rate.

Laparoscopic radical prostatectomy and resection of rectum performed together: first experience

Introduction Laparoscopy is an increasingly used approach in the surgical treatment of rectal cancer and prostate cancer. The anatomical proximity of the two organs is the main reason to consider performing both procedures simultaneously. Aim To present our first experience of laparoscopic rectal resection and radical prostatectomy, performed simultaneously, in 3 patients. Material and methods The first patient was diagnosed with locally advanced rectal cancer and tumor infiltration of the prostate and seminal vesicles. The other 2 patients were diagnosed with tumor duplicity. The surgery of the first patient started with laparoscopic prostatectomy except division of the prostate from the rectal wall. The next step was resection of the rectum, extralevator amputation of the rectum and vesicourethral anastomosis. In the other patients, resection of the rectum, followed by radical prostatectomy, was performed. Results The median follow-up was 12 months. The median operation time was 4 h 40 min, with blood loss of 300 ml. The operations and postoperative course were without incident in the case of 2 patients. However, 1 patient had stercoral peritonitis and a vesicorectal fistula in the early postoperative stage. Sigmoidostomy and postponed ureteroileal conduit were carried out. All patients were in oncologic remission. Conclusions Combined laparoscopic rectal resection and radical prostatectomy is a viable option for selected patients with locally advanced rectal cancer or tumor duplication. The procedures were completed without complications in 2 out of 3 patients.