Johannes Mischinger

Robot-assisted radical cystectomy and intracorporeal neobladder formation: on the way to a standardized procedure

BackgroundRobot-assisted radical cystectomy (RARC) with intracorporeal diversion has been shown to be feasible in a few centers of excellence worldwide, with promising functional and oncologic outcomes. However, it remains unknown whether the complexity of the procedure allows its duplication in other non-pioneer centers. We attempt to address this issue by presenting our cumulative experience with RARC and intracorporeal neobladder formation.MethodsWe retrospectively identified 62 RARCs in 50 men and 12 women (mean age 63.6 years) in two tertiary centers. Intracorporeal Studer neobladders were created, duplicating the steps of standard open surgery. Perioperative and postoperative variables and complications were analyzed using standardized tools. Functional and oncological results were assessed.ResultsThe mean operative time was 476.9 min (range, 310 to 690) and blood loss was 385 ml (200 to 800). The mean hospital stay was 16.7 (12 to 62) days with no open conversion. Perioperative complications were grade II in 15, grade III in 11, and grade IV in 5 patients. The mean nodal yield was 22.9 (8 to 46). Positive margins were found in in 6.4%. The 90- and 180-day mortality rates were 0% and 3.3%. The average follow-up was 37.3 months (3 to 52). Continence was achieved in 88% of patients. The cancer-specific survival rate and overall survival rate were 84% and 71%, respectively.ConclusionsA RARC with intracorporeal neobladder creation is safe and reproducible in ‘non-pioneer’ tertiary centers with robotic expertise with acceptable operative time and complications. Further standardization of RARC with intracorporeal diversion is a prerequisite for its widespread use.

Impact of perioperative chemotherapy on survival in patients with advanced primary urethral cancer: results of the international collaboration on primary urethral carcinoma

BACKGROUND To investigate the impact of perioperative chemo(radio)therapy in advanced primary urethral carcinoma (PUC). PATIENTS AND METHODS A series of 124 patients (86 men, 38 women) were diagnosed with and underwent surgery for PUC in 10 referral centers between 1993 and 2012. Kaplan-Meier analysis with log-rank testing was used to investigate the impact of perioperative chemo(radio)therapy on overall survival (OS). The median follow-up was 21 months (mean: 32 months; interquartile range: 5-48). RESULTS Neoadjuvant chemotherapy (NAC), neoadjuvant chemoradiotherapy (N-CRT) plus adjuvant chemotherapy (ACH), and ACH was delivered in 12 (31%), 6 (15%) and 21 (54%) of these patients, respectively. Receipt of NAC/N-CRT was associated with clinically node-positive disease (cN+; P = 0.033) and lower utilization of cystectomy at surgery (P = 0.015). The objective response rate to NAC and N-CRT was 25% and 33%, respectively. The 3-year OS for patients with objective response to neoadjuvant treatment (complete/partial response) was 100% and 58.3% for those with stable or progressive disease (P = 0.30). Of the 26 patients staged ≥cT3 and/or cN+ disease, 16 (62%) received perioperative chemo(radio)therapy and 10 upfront surgery without perioperative chemotherapy (38%). The 3-year OS for this locally advanced subset of patients (≥cT3 and/or cN+) who received NAC (N = 5), N-CRT (N = 3), surgery-only (N = 10) and surgery plus ACH (N = 8) was 100%, 100%, 50% and 20%, respectively (P = 0.016). Among these 26 patients, receipt of neoadjuvant treatment was significantly associated with improved 3-year relapse-free survival (RFS) (P = 0.022) and OS (P = 0.022). Proximal tumor location correlated with inferior 3-year RFS and OS (P = 0.056/0.005). CONCLUSION In this series, patients who received NAC/N-CRT for cT3 and/or cN+ PUC appeared to demonstrate improved survival compared with those who underwent upfront surgery with or without ACH.

Bilateral Laparoscopic Postchemotherapy Retroperitoneal Lymph-Node Dissection in Nonseminomatous Germ Cell Tumors-a Comparison to Template Dissection

PURPOSE Retroperitoneal lymph node dissection (RPLND) is performed in patients with advanced nonseminomatous (NSGCT) germ cell tumors and residual retroperitoneal mass post-chemotherapy. The extent of node dissection remains unclear. Ipsilateral template dissection is a compromise between morbidity and oncological efficacy. Here, we compare ipsilateral with primary bilateral laparoscopic (L)-RPLND after chemotherapy in terms of morbidity and oncological safety. PATIENTS AND METHODS Nineteen laparoscopic ipsilateral L-RPLNDs (Group A) after platinum-based chemotherapy in patients with clinical stage IIA-III NSGCT were performed, while 20 patients underwent primary bilateral L-RPLND (Group B). We included patients with residuals localized in the retroperitoneum >1 cm and a tumor marker negativity after chemotherapy. The patients in group B had nerve sparing based on their respective tumor volume. RESULTS All L-RPLND was successfully finished without conversion. Mean operative time in group A was 221 minutes and 270 minutes in group B (p=0.12). There were no deviations from the normal postoperative course in 36 cases. There was one Grade II complication (bleomycin-induced pneumonitis) in group A and 1 grade III complication (chylous ascites) in group B. The mean hospitalization time in both groups was 5 days (p=0.1). With regard to the overall rate of disease recurrence, no significant difference was found between both groups (HR=1.84; 95% CI 0.17-39.92; p=0.6109). CONCLUSIONS Postchemotherapy L-RPLND remains technically challenging. However, the morbidity of primary bilateral post-chemotherapy L-RPLND is similar to that of template dissection. Additional oncological safety is provided, which is particularly relevant in patients with more extensive retroperitoneal tumor volume.

Endoscopic inguinofemoral lymphadenectomy--extended follow-up.

BACKGROUND AND PURPOSE Inguinofemoral lymphadenectomy (IFLA) is a standard procedure for cancer of the external genitalia. Open lymphadenectomy (O-IFLA) exhibits complication rates of more than 50%. We are demonstrating our extended experience with a modified endoscopic approach (E-IFLA) for groin lymphadenectomy. PATIENTS AND METHODS Patients with nonpalpable as well as those with palpable nodes who had IFLA were identified. O-IFLA comprised both superficial and deep inguinal lymph node dissection. E-IFLA was performed using a three-trocar approach in the same field. We used a reduced CO2-pressure of <5 mm Hg. A suction drain was always placed. Perioperative data and postoperative outcomes were systematically assessed followed by statistical analysis. RESULTS We performed 62 IFLAs in 42 patients. Twenty-eight procedures were completed endoscopically. Follow-up was 55.8 months (2-87 mos). Mean operative time for O-IFLA was 101.7 minutes (38-195 min), being shorter than for E-IFLA (136.3 min, 87-186 min), P<0.001. Both groups are comparable regarding the number of nodes (O-IFLA 7.2, 2-16 vs E-IFLA 7.1, 4-13) as well as with regard to the number of positive nodes (O-IFLA 1.8 vs E-IFLA 1.6). Secondary wound healing and leg edema were extremely rare events (1/28) after E-IFLA. The overall complication rate was 7.1%. Complications appeared in 55.3% of the O-IFLA-cases. There were no problems related to CO2 insufflation. Local recurrence rates were identical in both groups. CONCLUSIONS O-IFLA and E-IFLA are efficient with respect to oncologic safety. E-IFLA is technically more challenging. E-IFLA can avoid secondary wound healing and lymphatic complications. E-IFLA is a safe procedure while a reduction of CO2 pressures optimizes the safety profile. Because cancer control rates remained equivalent during an extended follow-up, oncologic durability could be confirmed.

Serum receptor activator of nuclear factor κB ligand (RANKL) levels predict biochemical recurrence in patients undergoing radical prostatectomy

There is increasing evidence that the receptor activator of nuclear factor κB ligand (RANKL) pathway not only contributes to the development of bone metastases, but also influences tumour biology in earlier stages of cancer. The study shows that preoperative serum levels of RANKL and its inhibitor osteoprotegerin (OPG) have a prognostic impact in patients undergoing radical prostatectomy for clinically localized prostate cancer. Both high levels of RANKL and a higher RANKL/OPG ratio are independent predictors of early biochemical recurrence in these patients.

Significance of apoptotic and non-apoptotic disseminated tumor cells in the bone marrow of patients with clinically localized prostate cancer.

Disseminated tumor cells (DTC) can be detected in a high proportion of patients with localized solid malignancies. In prostate cancer (PC), determination of DTCs is critically discussed as there are conflicting results on their prognostic value. The aim of the present study was to evaluate the presence and prognostic role of DTCs in PC patients with a high risk of disease recurrence.

Totally intracorporeal replacement of the ureter using whole-mount ileum.

Ileal ureter is a suitable treatment option for patients with long ureteral strictures. Minimally invasive techniques have been shown to be as safe as open technique and superior in terms of postoperative recovery. We report the first case of laparoscopic totally intracorporeal replacement of ureter using whole-mount ileum in a patient with right-sided long ureteral stricture. The operative time was 150 minutes, and there were no complications. We have demonstrated the safety and feasibility of laparoscopic intracorporeal ileal ureter with possible advantage of shorter operative time compared with the robotic-assisted technique reported recently.

Intracorporeal ileal ureter replacement using laparoscopy and robotics.

Introduction Ileal ureter is a suitable treatment option for patients with long ureteric strictures. Minimally invasive techniques have been shown to be as safe as open techniques but superior in terms of post–operative recovery. We report our experience using minimally invasive techniques for total intracorporeal ureteral replacement. Material and methods A chart review revealed five patients who underwent intracorporeal ileal ureter using minimally invasive techniques in the preceding 5 years. 4 patients underwent conventional laparoscopic surgery and 1 patient underwent robotic–assisted surgery. Patients characteristics, perioperative data and functional outcomes as well as a detailed description of surgical technique are reported. In all 5 of these patients, the ileal ureter was performed completely intracorporeally. Results The median age of our patients is 61 (range 42–73). The median operative time was 250 minutes (range 150–320) and median blood loss was 100 ml (range 50–200). The median hospital stay was 8 days (range 6–10) and there were no major perioperative complications reported. At median follow up of 22 months (range 4–38), there were no recurrences of strictures or any other complications. Conclusions We have demonstrated the safety and feasibility of minimally invasive intracorporeal ileal ureter. Numbers are still small but its application is likely to grow further.

Y Pouch Neobladder—A Simplified Method of Intracorporeal Neobladder After Robotic Cystectomy

In recent years, robot-assisted radical cystectomy (RARC) has shown similar oncologic outcomes compared with the gold standard open radical cystectomy with the added benefit of less blood loss and shorter hospital stay. Robot-assisted cystectomy with intracorporeal ileal neobladder is a complex surgical procedure and is usually performed in centers with experienced surgeons. We propose robot-assisted cystectomy with intracorporeal neobladder using the Y pouch previously described in open radical cystectomy. We think that the Y pouch is easier to perform than conventional spherical pouches without compromising functional outcomes. It may therefore be a good alternative for patients undergoing RARC with intracorporeal diversion.

Stepwise Application of Urine Markers to Detect Tumor Recurrence in Patients Undergoing Surveillance for Non-Muscle-Invasive Bladder Cancer

Background. The optimal use of urine markers in the surveillance of non-muscle-invasive bladder cancer (NMIBC) remains unclear. Aim of the present study was to investigate the combined and stepwise use of the four most broadly available urine markers to detect tumor recurrence in patients undergoing surveillance of NMIBC. Patients and Methods. 483 patients with history of NMIBC were included. Cytology, UroVysion, fluorescence in situ hybridization (FISH), immunocytology (uCyt+), and NMP22 ELISA were performed before surveillance cystoscopy. Characteristics of single tests and combinations were assessed by contingency analysis. Results. 128 (26.5%) patients had evidence of tumor recurrence. Sensitivities and negative predictive values (NPVs) of the single tests ranged between 66.4–74.3 and 82.3–88.2%. Two-marker combinations showed sensitivities and NPVs of 80.5–89.8 and 89.5–91.2%. A stepwise application of the two-test combinations with highest accuracy (cytology and FISH; cytology and uCyt+; uCyt+ and FISH) showed NPVs for high-risk recurrences (G3/Cis/pT1) of 98.8, 98.8, and 99.1%, respectively. Conclusions. Combinations of cytology, FISH, immunocytology, and NMP22 show remarkable detection rates for recurrent NMIBC. Stepwise two-test combinations of cytology, FISH, and immunocytology have a low probability of missing a high-risk tumor. The high sensitivities may justify the use of these combinations in prospective studies assessing the use of urine markers to individualize intervals between cystoscopies during follow-up.