Klaus P. Juenemann

Refluxing chimney versus nonrefluxing LeDuc ureteroileal anastomosis for orthotopic ileal neobladder: a comparative analysis for patients with bladder cancer.

PURPOSE Radical cystectomy and various techniques of urinary diversion are gold standard treatments for invasive bladder cancer. However, postoperative hydronephrosis is a common complication in these patients. A special focus was placed on the type of ureteroileal anastomosis used with 2 different techniques performed at 1 institution. MATERIALS AND METHODS Between 1995 and 2003 a total of 106 consecutive patients with bladder cancer underwent cystectomy followed by construction of an ileal neobladder. The nonrefluxing technique of ureter tunneling described by LeDuc and the refluxing chimney technique used for ureter implantation into the ileum-neobladder were compared. Hydronephrosis due to ureteral strictures was studied immediately following surgery and up to 5 years after surgery. RESULTS A total of 204 RU were included in the study. The LeDuc technique was used in 132 RU (64%) and the chimney technique was used in 72 RU (36%). Hydronephrosis rate of 2% were found in each of the 2 groups after 5 years of followup. CONCLUSIONS Postoperative hydronephrosis due to ureteral strictures is observed at the same rate during long-term followup with the LeDuc and chimney techniques. We favor the chimney technique compared to the LeDuc tunnel due to easier technical preparation and a better chance to identify the ureters endoscopically at a later time. The chimney does give extra length to reach the ureteral stump, especially in cases of distal ureteral carcinoma in situ.

The role of the carbachol test and concomitant diseases in patients with nonobstructive urinary retention undergoing sacral neuromodulation

The aim of this study was to evaluate the percutaneous nerve evaluation (PNE) test success in patients with nonobstructive urinary retention. A total of 24 PNE tests were performed in patients with nonobstructive urinary retention and in 18 patients, a carbachol test was performed during urodynamics. The diagnosis relating to the acontractile detrusor was also assessed and compared to the outcome of the PNE test. The PNE test was successful in eight of 24 patients (33.3%) with the the highest success rate being observed in patients after hysterectomy (80%). It was successful in five of 12 patients with negative carbachol tests and in three of six patients with positive carbachol tests. We conclude that sacral neuromodulation is an effective treatment option in patients with nonobstructive urinary retention. PNE tests should be performed in all patients with therapy resistant nonobstructive urinary retention, because predictive factors do not exist.

Extended Lymphadenectomy “Step by Step” in Patients Undergoing Radical Prostatectomy

OBJECTIVES To describe a surgical technique of pelvic lymph node dissection (PLND) in prostate cancer patients. The idea was to standardize the procedure of PLND and to increase the significance of lymphadenectomy as a part of radical prostatectomy (RP). The best ways to achieve this are (1) to describe the surgical procedure in detail, (2) to improve the knowledge of metastatic spread, and (3) to improve the management of complications. METHODS One-hundred six patients with localized prostate carcinoma were treated with RP, including extended PLND. The number of removed lymph nodes (LNs) was correlated with histology and compared with that reported in the literature. Our aim was to observe technical differences that probably accrue in clinical outcomes. We proposed a conceptual schema of PLND. RESULTS LN metastases were detected in 15 of 106 patients (14.15%). Positive sentinel LNs were detected in 11 of these 15 patients (73.3%). The average number of removed LNs was 20.5 (range +5). In 4 of 15 patients (26.5%), positive LNs were found in the fossa obturatoria; in 4 patients (26.5%) in the region of the external iliac artery; in 3 patients (20%) in the internal LN region; in 2 patients (13%) in the region of the common iliac artery; in 1 patient (7%) in the presciatic area; and in 1 patient (7%) in the sacral region. CONCLUSIONS The standard routine was: (1) dissection of LN tissue along the common iliac artery, (2) dissection of LN tissue in the presciatic area, (3) dissection of LN tissue parasacral, and (4) peritoneal fenestration.

Barry shunt for treatment of a 76-hour stuttering priapism without subsequent erectile dysfunction

Introduction This paper reports treatment of a 76-hour low-flow priapism with a shunting procedure that was first described by Barry in 1976. We were able to observe the preservation of erectile function despite the long period of ischemia. A review of the literature shows that there are few reports of erectile function recovery after a priapism of similar duration. Materials and methods A 42-year-old patient presented with a 76-hour priapism, probably caused by consumption of alcohol and illegal drugs. A Barry Shunt procedure was performed. The erectile function of the patient was assessed by means of International Index of Erectile Function score over a follow-up period of 30 months. Moreover, we reviewed different surgical options for treatment of priapism in the literature. Results Partial return of erection without sexual arousal occurred on two occasions during the 10-day hospitalization, but was treated by manipulation of the penis, ie, by milking the tumescence into the shunt. After 3 months, the shunt was still palpable as a subcutaneous swelling. Six months postoperatively, the residual swelling had disappeared. The International Index of Erectile Function score was of 21 without phosphodiesterase type 5 inhibitors after a follow-up of 2.5 years. Conclusion Barry shunt is an effective alternative surgical option for the treatment of low-flow priapism. In the case of our patient, it was also effective after a 76-hour-lasting priapism.

Preoperatively evaluated bladder wall tension as a prognostic parameter for postoperative success after surgery for bladder outlet obstruction

OBJECTIVES To evaluate a novel method for the determination of bladder wall tension (BWT) and to correlate these findings with postoperative persistent residual urine, postoperative uroflow, International Prostate Symptom Score, and quality-of-life index in patients with bladder outlet obstruction. METHODS In 28 male patients with prostate enlargement or bladder neck sclerosis undergoing surgical treatment, the preoperative BWT was determined after urodynamic investigation and ultrasound determination of bladder weight. The patients were divided into two groups: group 1 (n = 24), postoperative residual urine volume less than 50 mL; and group 2 (n = 4), persistent residual urine volume greater than 50 mL. Five patients in group 1 were unobstructed in accordance with the Abrams-Griffiths nomogram. This group was compared separately with group 2, in which all 4 patients were also classified as unobstructed. RESULTS The preoperative BWT in group 1 was 5.2 +/- 4.1 N/cm(2), significantly different from the preoperative BWT in group 2 (0.98 +/- 0.3 N/cm(2)). The BWT in the 5 unobstructed patients in group 1 (3.4 +/- 1.3 N/cm(2)) was significantly greater than that in patients in group 2. BWT was the sole parameter that was distinctly different between these 5 patients and the patients in group 2, with a significant influence on postoperative uroflow, International Prostate Symptom Score, and quality-of-life index. CONCLUSIONS The results of this pilot study show that the determination of BWT allows further evaluation of the detrusor function. Especially in patients classified as unobstructed according to the Abrams-Griffiths nomogram, preoperative determination of the BWT could become a supplemental and important parameter with predictive value for postoperative success in patients with prostate enlargement or bladder neck sclerosis.