Martin Marszalek

Laparoscopic and Open Partial Nephrectomy: A Matched-Pair Comparison of 200 Patients

BACKGROUND Laparoscopy is currently challenging the role of the open approach for nephron-sparing surgery (NSS), yet comparative studies on this issue are scant. OBJECTIVE To compare surgical, oncologic, and functional outcomes after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN). DESIGN, SETTING, AND PARTICIPANTS We undertook matched-pair (age, sex, tumour size) analysis of patients who underwent elective NSS for renal masses either by laparoscopic (Klagenfurt) or open (Vienna) access. MEASUREMENTS Surgical data, complications, histologic and oncologic data, and short- and long-term renal function of the open and laparoscopic groups were compared. RESULTS AND LIMITATIONS In total, 200 patients matched for age, sex, and tumour size entered the study after either LPN or OPN and were followed for a mean of 3.6 yr. Surgical, ischemia, and hospitalisation times were shorter in the LPN group (p<0.001). Blood loss and complication rates were comparable in both groups. Malignant tumours were pT1 stage renal-cell cancer only in both groups. The positive surgical margin (PSM) rate was 4% after LPN and 2% after OPN (p=0.5); positive margins were not a risk factor for disease recurrence. Kaplan-Meier estimates of 5-yr local recurrence-free survival (RFS) were 97% after LPN and 98% after OPN (p=0.8); the respective numbers for distant free survival were 99% and 96% (p=0.2). Five-year overall survival (OS) for patients with pT1 stage renal cell carcinoma (RCC) was 96% after LPN and 85% after OPN. The decline in glomerular filtration rate at the last available follow-up (LPN: 10.9%; OPN: 10.6%) was similar in both groups (p=0.8). We recognise the retrospective nature, limited follow-up, and sample size as shortcomings of this study. CONCLUSIONS In experienced hands, LPN provides similar results compared to open surgery. PSM rates were comparable after LPN and OPN. Current experience questions the indication of secondary nephrectomy in these patients.

Positive Surgical Margins After Nephron-Sparing Surgery

CONTEXT Little is known on the natural history of positive surgical margins (PSMs) in partial nephrectomy (PN). Accumulating data suggest that secondary nephrectomy might not be necessary in all patients with PSMs after PN. OBJECTIVE Provide an overview on incidence and risk factors for PSMs after partial nephrectomy and on the rate of local and distant disease recurrence related to PSMs. We also provide recommendations on how to avoid and how to treat PSMs after PN. EVIDENCE ACQUISITION A nonsystematic literature research was based on Medline, Scopus, and Web of Science queries on these keywords: nephron-sparing surgery, partial nephrectomy/ies, and margin. Only human studies (original research) published in English were included. EVIDENCE SYNTHESIS PSMs are present in 0-7% of patients after open PN, in 0.7-4% after laparoscopic PN, and in 3.9-5.7% after robot-assisted PN. The thickness of healthy parenchyma surrounding the tumour is irrelevant as long as complete tumour removal is achieved. The coincidence of a highly malignant tumour and PSM increases the risk of local recurrence. Intermediate follow-up data indicate that the vast majority of patients with PSMs will not experience local or distant tumour recurrence. Frozen-section analysis for evaluation of resection margins during PN is of minor clinical significance, as the surgeons gross assessment of macroscopically negative margins provides reliable results. CONCLUSIONS PSMs in PN are rare. As indicated by intermediate follow-up data, the majority of patients with PSMs after PN remain without disease recurrence, and a surveillance strategy seems preferable to surgical reintervention.

Nocturia is an age-independent risk factor for hip-fractures in men.

Nocturia is a highly prevalent symptom in the elderly and a common reason for interrupted sleep resulting in dizziness, worse daytime functioning and higher risk of falls. The aim of this study was to determine the role of nocturia as a risk factor for hip‐fractures in men.

Are Lower Urinary Tract Symptoms Influenced by Metabolic Syndrome

OBJECTIVES To determine the role of the metabolic syndrome (MS) in the genesis of lower urinary tract symptoms (LUTS) in both sexes. The MS and LUTS are highly prevalent disorders, both increasing with increasing age. METHODS Participants in a health-screening project underwent a detailed health examination, including all factors associated with the MS, and were assessed regarding LUTS. The MS was defined according to the International Diabetes Federation consensus definition of 2005, and LUTS were quantified using the International Prostate Symptom Score (IPSS). RESULTS A total of 2371 men (mean age 46.1 years) and 731 women (mean age 53.9 years) were analyzed. In the men, moderate-to-severe LUTS (IPSS >7) were present in 13.1%; in the women, the corresponding value was 23.5%. The proportion of the MS diagnosed during the health investigation was 33.8% in the men and 30.2% in the women. On multiple linear regression analysis, the MS was not associated with the IPSS, IPSS obstructive or irritative subscore, or LUTS. The proportion of LUTS and mean IPSS did not significantly differ regarding the presence or absence of the MS in either sex. CONCLUSIONS According to our results, the MS did not turn out to be significantly and independently involved in the genesis of LUTS in men or women.

Chronic Pelvic Pain and Lower Urinary Tract Symptoms in Both Sexes: Analysis of 2749 Participants of an Urban Health Screening Project

BACKGROUND Recent studies question the role of the prostate as the key factor in the pathogenesis of chronic pelvic pain syndrome (CPPS). OBJECTIVE To compare symptoms related to CPPS and lower urinary tract symptoms (LUTS) in both sexes. DESIGN, SETTING, AND PARTICIPANTS Participants of a voluntary health examination in Vienna. INTERVENTION AND MEASUREMENTS All participants completed a detailed questionnaire containing the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), with the female homolog of each male anatomical term use on questionnaires for female participants, the International Prostate Symptom Score (IPSS), and additional questions on pelvic pain. Furthermore, all participants underwent a detailed health investigation performed by a general practitioner. RESULTS AND LIMITATIONS The study cohort comprised 1768 men and 981 women. The mean NIH-CPSI was 7.2+/-0.1 in women and 3.8+/-0.2 in men (p<0.001). In subject up to the age of 70 yr, the NIH-CPSI was higher in women (p<0.001). The NIH-CPSI increased with age in men (p<0.001), yet not in women (p=0.4). The prevalence of symptoms suggestive of CPPS in this selected population was 5.7% in women and 2.7% in men, and was higher in premenopausal women (p=0.03). Until the age of 50 yr, NIH-CPSI pain score in women exceeded that of men (p<0.001). The mean IPSS was higher in women (p<0.001). Storage symptoms were higher in women up to 60 yr, and voiding symptoms were higher in men above 60 yr. In men and women with symptoms suggestive of CPPS, the mean IPSS was significantly higher compared with those without CPPS symptoms (p<0.001). Limitations of our study are (1) that a urological evaluation was not performed and (2) that the questionnaire was not formerly validated for females. CONCLUSION The preponderance of CPPS in females raises questions about the etiological role of the prostate in all cases with chronic pelvic pain and suggests that other pathomechanisms are likely to be involved.

Sexual Function after Tension-Free Vaginal Tape Procedure

Introduction: Aim of this cross-sectional study was to analyze the sexual function of women after tension-free vaginal tape (TVT) procedure. Patients and Methods: To evaluate the female sexual function after the TVT procedure, we designed a 36-item questionnaire including 21 questions on incontinence, 15 questions on sexuality and 3 questions on the personal impression of the procedure. Diagnostic workup consisted of a detailed medical history, urinalysis, postvoid residual urine volume assessment, ultrasound of the kidney and a urodynamic study. Results: Fifty-two women completed the entire questionnaire. Overall, 82.7% of the women were satisfied with the TVT procedure. A proportion of 74.0% indicated that they became totally continent after the operation. One third of the sexually active women reported an improvement of their sexual life after TVT, 14.3% a worsening, and 52.4% reported no change. Deterioration of sexual function was significantly associated with de novo urge, dyspareunia and sensation of postvoid residual urine volume. Conclusion: In summary, our investigations showed that the influence of the TVT procedure on female sexual function is evident, but of low impact, and in general will not be of relevance.

Laparoscopic partial nephrectomy: a matched-pair comparison of the transperitoneal versus the retroperitoneal approach.

OBJECTIVES To compare surgical and functional results of both surgical approaches to endoscopic partial nephrectomy. It is currently performed either by the transperitoneal (t) or the retroperitoneal (r) approach. METHODS This was a retrospective, matched-pair comparison of 105 patients who underwent either transperitoneal laparoscopic (Graz) or retroperitoneoscopic (Klagenfurt) partial nephrectomy for clinical T1a renal masses. RESULTS A total of 35 patients after transperitoneal laparoscopic and 70 patients after retroperitoneoscopic partial nephrectomy were included to this analysis after matching for age (T: 59.3 vs R: 60.1 a), preoperative glomerular filtration rate (GFR) (T: 93.2 vs R: 96.1 mL/min) and tumor size (T: 2.4 vs R: 2.5 cm). Nephrometry scores were comparable between groups and were low, medium, and high in 54.3%, 45.7%, and 0% (t) and 55.7%, 42.9%, and 1.4% (r) of patients (P = .9). Operative time (T: 139.3 minutes vs. R: 83.9 minutes; P < .001) and hospitalization (T: 7 days, R: 5 days; P < .001) were shorter in the retroperitoneoscopic group. Ischemia time (T: 24.3 minutes, R: 22.6 minutes) and postsurgical GFR (T: 86.6 vs R: 90.0 mL/min), postsurgical GFR-decrease (T: 7.1%, R: 6.2%, P = .9) and decline of hemoglobin (T: 17.1%, R: 16.6%) were comparable. Complications were 4 nephrectomies (T: n = 1, R: n = 3), 2 revisions for hemorrhage (R: n = 2), 4 pneumothorax (R: n = 4), and 2 urinary fistulas (T: n = 2). The positive surgical margin rate was comparable between groups (T: n = 3, R: n = 5). CONCLUSIONS Transperitoneal laparoscopic and retroperitoneoscopic partial nephrectomy provide comparable surgical and functional results. One advantage of the retroperitoneoscopic access seems to be a shorter total surgical time.

Palliative transurethral resection of the prostate: functional outcome and impact on survival

To assess the long‐term functional and oncological outcome in a consecutive series of patients undergoing palliative transurethral resection of the prostate (pTURP).

Clinical Parameters and Semen Analysis in 716 Austrian Patients With Varicocele

OBJECTIVES To evaluate different clinical parameters in association with the presence and severity of varicocele in a large group of Austrian men. METHODS Records of 716 consecutive patients with clinical varicocele and infertility, who visited our andrology unit from 2001 to 2007, were retrospectively evaluated. The presence, grade, and side of any varicocele were recorded; varicoceles were confirmed by Doppler sonography. Semen samples, serum follicle-stimulating hormone, luteinizing hormone, estradiol, and testosterone levels were also assessed in all patients. RESULTS Mean age was 29.6 +/- 0.3 years; 30% of patients presented with grade I varicocele, 39.0% with grade II, and 30.3% with grade III varicocele. About 33.3% of patients presented with normozoospermia, followed by asthenozoospermia (17.9%), oligoasthenoteratozoospermia syndrome (14.2%), and oligozoospermia (13.2%). Sperm density significantly decreased with increasing grade of varicocele. Body mass index was inversely proportional to varicocele. Serum testosterone levels were higher in grade III varicoceles (5.7 +/- 0.2 nmol/L) compared with grade I (4.9 +/- 0.2 nmol/L) and grade II (5.0 +/- 0.1 nmol/L) varicoceles (P <.001; range, 0.4-16.6 nmol/L). CONCLUSIONS To our knowledge the current report is the first to describe a direct relationship between grade of varicocele and semen quality. Grade III varicocele was associated with decreased semen quality and, interestingly, with higher testosterone levels. Our study confirmed previous reports regarding the relationship between varicoceles and body mass index.

Adjustable Continence Therapy for Female Urinary Incontinence: A Minimally Invasive Option for Difficult Cases

Aim: To assess the role of Adjustable Continence Therapy® (ACT) as a minimally invasive treatment for women with urinary incontinence (UI) after failed previous incontinence surgery or when conventional surgical treatment was considered problematic. Material and Methods: The ACT device consists of two balloons implanted at the level of the bladder neck using a paraurethral/vaginal approach with the aim of coapting the urethra. Balloon filling can be adjusted postoperatively via a port placed in the labia majora. Results: 41 women with a mean age of 73 (range 42–93) years were evaluated. 15 (38%) women had failed previous UI surgery with 83% having undergone prior pelvic surgery. Mean follow-up was 25 (5–60) months. Adjustment of the ACT balloons was necessary in 28 women (69%). Overall, 44% of women became fully continent, 15% reported a significant improvement of UI, a further 29% had a slight improvement, while 12% indicated no change. ACT-related complications occurred in 16 (39%) patients, including balloon migration, transient urinary obstruction and balloon leakage. Conclusions: ACT is an attractive minimally invasive option for women with UI with previous failed incontinence surgery or when conventional incontinence surgery carries a high risk of failure.