Jörg Simon

ILEAL NEOBLADDER AND LOCAL RECURRENCE OF BLADDER CANCER: PATTERNS OF FAILURE AND IMPACT ON FUNCTION IN MEN

PURPOSE Creation of an ileal neobladder has become a standard procedure in patients undergoing cystectomy for invasive bladder cancer. We evaluated the impact of local recurrence on ileal neobladder function and survival. MATERIALS AND METHODS Between April 1986 and February 1997, 357 men underwent radical cystectomy and ileal neobladder substitution at our institution. We retrospectively reviewed the records of these patients to determine patterns of local recurrence and survival rates. RESULTS Local recurrence developed in 43 of the 357 patients (12%), in whom median survival plus or minus standard deviation was 17 +/- 1.6 months and median time to recurrence was 10 months (range 2 to 41). Of the 43 patients with local recurrence at followup 36 had local advanced cancer on the final pathological evaluation (stage pT3a or node positive, or greater). A total of 17 patients (43%) had concomitant distant metastasis. Of the 43 patients 3 are alive at 36, 48 and 147 months, respectively. Death was due to disease in 36 cases, chemotherapy related complications in 3 and another cause in 1. Of the 43 patients 40 maintained good neobladder function. Local recurrence interfered with the upper urinary tract in 24 cases, neobladder in 10 and intestinal tract in 7. The neobladder was removed only in 1 patient due to a neovesical intestinal fistula. CONCLUSIONS The local recurrence rate after orthotopic urinary reconstruction is 12%. Survival after local recurrence is diagnosed is limited despite multimodality therapy. However, most patients may anticipate normal neobladder function even in the presence of recurrent disease or until death. Thus, creating orthotopic diversion after cystectomy in patients with locally advanced bladder cancer, including macroscopically or microscopically positive lymph nodes, is safe.

Intensifying the saturation biopsy technique for detecting prostate cancer after previous negative biopsies: a step in the wrong direction.

To report the results using an extensive saturation biopsy in men with negative prostate biopsies but in whom there is still a clinical suspicion for carcinoma.

Detection rate of histologically insignificant prostate cancer with systematic sextant biopsies and fine needle aspiration cytology.

PURPOSE We evaluate the detection rate of insignificant prostate cancer and the rate of significant prostate cancer overlooked in the results of systematic sextant biopsy and fine needle aspiration biopsy of the prostate of asymptomatic men with serum prostate specific antigen concentrations less than 4.0 ng./ml. MATERIALS AND METHODS We analyzed specimens from 133 consecutive patients with a mean age of 60 years undergoing cystoprostatectomy for bladder cancer. Six systematic biopsy specimens and 2 fine needle aspiration cytology samples were taken from the prostate immediately after cystoprostatectomy. The specimens were step sectioned and examined for prostate cancer. Insignificant prostate cancer was defined as any cancer with an aggregate volume 0.5 cm.3 or less. RESULTS Incidental prostate cancer was found in 58 of the 133 patients (44%). Tumor volume was 0.5 cm.3 or less in 47 cases. Sextant biopsy detected 7 cancers, including 4 of 47 (9%) that were insignificant and 3 of 11 (27%) that were significant. Fine needle aspiration cytology also detected 7 cancers, including 3 (6%) and 4 (36%) that were insignificant and significant, respectively. CONCLUSIONS Systematic sextant biopsy and fine needle aspiration cytology each diagnose prostate cancer in about 5% of asymptomatic men who have normal digital rectal examination and serum prostate specific antigen less than 4.0 ng./ml. However, many of the cancers thus detected are insignificant and most of the significant cancers are missed. Therefore, routine screening of such patients with sextant biopsy or aspiration cytology does not appear to be justified.

Laparoscopic partial nephrectomy with selective control of the renal parenchyma: initial experience with a novel laparoscopic clamp.

To report a laparoscopic device that facilitates regional ischaemia in laparoscopic partial nephrectomy (LPN).

Optimized haemostasis in nephron-sparing surgery using small-intestine submucosa

BackgroundThe indications for nephron-sparing surgery are expanding constantly. One major contributing fact for this development is the improvement of haemostatic techniques following excision of the tumor. Nevertheless, postoperative bleeding complications still occur. To prevent this, we prospectively studied the effect of application of small-intestine submucosa (SIS) over the renal defect.MethodsWe performed 55 nephron-sparing surgeries applying SIS between 08/03 and 10/06 in 53 pts. (mean age: 59 yrs., range 29 – 79 yrs.). After resection of the renal tumor and application of a haemostyptic agent, we used SIS to secure and apply compression on the defect.ResultsThe final pathology revealed clear-cell and papillary carcinoma, papillary adenoma, oncocytoma, and angiomyolipoma in 39 (70.9%), 6 (10.9), 1 (1.8%), 2 (3.6%) and 7 (12.7%) patients, respectively. The 45 malignant lesions (81.8%) were classified as pT1a and pT1b in 35 (77.8%) and 10 (22.2%) patients, respectively. The median tumor size was 4.5 cm (range: 1.3 – 13 cm). The median operating time was 186 min (range: 90 – 260 min). 18 (32.7%) procedures were performed without ischemia. 23 (41.8%) and 14 (25.5%) cases were operated in in-situ cold and warm ischemia, respectively. The median intraoperative blood loss was 730 cc (range: 100 – 2500 cc). No open operative revision was indicated due to postoperative bleeding complications. Furthermore, there was no necessity to substitute persistent blood loss from the drains postoperatively. No urinoma occurred.ConclusionSIS is a highly effective and easy-to-use instrument for preventing postoperative bleeding and urinary fistula complications in nephron-sparing surgery.

Maximum tensile force of different suture techniques in reconstruction of the renal remnant after nephron-sparing surgery.

BackgroundIn nephron-sparing surgery, the closure of the renal remnant is one of the major critical steps in preventing possible complications. Several suture techniques can be used for this purpose. The type of suture used depends on the discretion of the surgeon and not on validated experimental data.MethodsIn an experimental setting, the renal remnant of a standardized defect in 20 porcine kidneys (with and without an intact renal capsule) was reconstructed using three different suture techniques (simple, vertical, and horizontal mattress suture). The maximum tensile force before the suture tears through the renal remnant was recorded.ResultsThe horizontal mattress suture attains the highest maximum tensile force by far. The values of the simple and vertical mattress sutures are surpassed, with a respective increase of 140 and 83% if the capsule is intact and 172 and 109% if the capsule is not intact. If an intact renal capsule is present, the maximum tensile force in each suture technique increases 43–63%.ConclusionsThe data suggest that of all tested suture techniques, the horizontal mattress suture provides the best adaptation strength before the suture tears through the renal parenchyma/capsule. Furthermore, it is recommended that the kidney capsule be included in the reconstructive suture because this significantly contributes to the safety of the procedure.

Optimizing Selective Renal Clamping in Nephron-Sparing Surgery Using the Nussbaum Clamp

OBJECTIVES Selective clamping techniques are an attractive surgical option in nephron-sparing surgery. We describe the use of the Nussbaum clamp for this procedure and point out the advantages of this clamping technique. TECHNICAL CONSIDERATIONS The perirenal fat overlying the tumor is removed from the kidney. It is unnecessary to expose the renal artery and vein. The Nussbaum clamp is placed around the tumor 1 to 2 cm proximal to the line of resection. Afterward, the tumor is excised and a hemostasis achieved. Twelve patients underwent nephron-sparing surgery that used the Nussbaum clamp between January 2006 and November 2006. The indications for nephron-sparing surgery were complicated renal cysts or a suspected renal carcinoma in 3 and 9 patients, respectively. The location of the tumor was in the upper pole, lower pole, middle portion, and in a horseshoe-shaped kidney in 4, 6, 1, and 1 patient, respectively. The median time of selective clamping and intraoperative blood loss was 19 minutes (range 12 to 31 minutes) and 300 mL (range: 100 to 500 mL), respectively. CONCLUSIONS The Nussbaum clamp is a commercially available, easy-to-use and effective instrument for selective clamping in nephron-sparing surgery.

Gender Specific Differences in Disease-Free, Cancer Specific and Overall Survival after Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis

Purpose: We summarize the evidence on gender specific differences in disease‐free, cancer specific and overall survival after radical cystectomy for bladder cancer. Materials and Methods: We performed a systematic literature search of MEDLINE®, Embase® and the Cochrane Library in July 2017. Studies evaluating gender specific differences in disease‐free, cancer specific or overall survival after radical cystectomy for bladder cancer were included in study. Analyses included random effect meta‐analysis, subgroup analyses, meta‐influence and cumulative meta‐analyses. Funnel plots and the Egger test were used to assess publication bias. Results: Of the 3,868 studies identified during the literature search 59 published between 1998 and 2017 were included in analysis. Of the studies 30 in a total of 38,321 patients evaluated disease‐free survival, 44 in a total of 69,666 evaluated cancer specific survival and 26 in a total of 30,039 evaluated overall survival. Random effect meta‐analyses revealed decreased disease‐free, cancer specific survival and overall survival in female patients than in their male counterparts. Pooled estimates showed a HR of 1.16 (95% CI 1.06–1.27, p = 0.0018) for disease‐free survival, 1.23 (95% CI 1.15–1.31, p <0.001) for cancer specific survival and 1.08 (95% CI 1.03–1.12, p = 0.0004) for overall survival. Subgroup analyses confirmed impaired disease‐free, cancer specific and overall survival in female patients in all strata. Publication bias was evident only for studies of cancer specific survival (Egger test p = 0.0029). After adjusting for publication bias by the trim and fill method the corrected pooled estimated HR of cancer specific survival was 1.13 (95% CI 1.05–1.21, p = 0.0012). Conclusions: Female patients who underwent radical cystectomy for bladder cancer demonstrated worse disease‐free, cancer specific and overall survival than their male counterparts. The multifactorial etiology might include epidemiological differences, gender specific health care discrepancies and hormonal influences.