Michael Probst

Robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic ileal neobladder.

PURPOSE To describe our technique of robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic neobladder (Hautmann) for treatment of transitional cell carcinoma of the bladder. METHODS We describe our surgical technique in the worldwide first attempt to perform a robotic-assisted laparoscopic radical cystectomy and completely intra-abdominal formation of an orthotopic neobladder. The DaVinci System (Intuitive Surgical, Mountain View, CA, USA) was utilized to perform the procedure. RESULTS Utilizing the DaVinci System the operation could be performed without any complications. Operating time was 8.5 hours, blood loss was 200 ml. The oncologic as well as the functional result of the reservoir were excellent. DISCUSSION We here demonstrated that sophisticated laparoscopic procedures like the intra-abdominal formation of an orthotopic neobladder are accomplishable with robotic assistance.

Impact of Overweight and Pneumoperitoneum on Hemodynamics and Oxygenation during Prolonged Laparoscopic Surgery

BackgroundAnesthesia adversely affects respiratory function and hemodynamics in obese patients. Although many studies have been performed in morbidly obese patients, data are limited concerning overweight patients [BMI 25–29.9 kg m−2]. The aim of this study was to evaluate the effects of prolonged pneumoperitoneum in Trendelenburg position on hemodynamics and gas exchange in normal and overweight patients.MethodsWe studied 15 overweight and 15 non-obese [BMI 18.5–24.9 kg m−2] patients who underwent totally endoscopic robot-assisted radical prostatectomy under general anesthesia with an inspired oxygen fraction of 0.5. A standardized anesthetic regimen was used, and patients were examined at standard times: after induction of anesthesia and Trendelenburg posture, every 30 minutes after establishing pneumoperitoneum, and after the release of the pneumoperitoneum with the patient still in Trendelenburg position.ResultsAfter induction of anesthesia and Trendelenburg positioning arterial oxygen pressure [PaO2] and alveolar-arterial difference in oxygen tension [AaDO2] differed significantly between both groups with lower PaO2 [235 ± 27 versus 164 ± 51 mmHg] and higher AaDO2 [149 ± 48 versus 76 ± 28 mmHg] values in overweight patients. During pneumoperitoneum, PaO2 transient increased above baseline values in overweight patients, whereas AaDO2 decreased. Hemodynamic parameters [HR, MAP, and CVP] did not differ significantly between groups.ConclusionsArterial oxygenation and AaDO2 are significantly impaired in overweight patients under general anesthesia in Trendelenburg posture. In overweight patients pneumoperitoneum transient reduced the impairment of arterial oxygenation and lead to a decrease in AaDO2. Hemodynamic parameters were not affected by body weight.

Renal transplantation in the elderly: surgical complications and outcome with special emphasis on the Eurotransplant Senior Programme

BACKGROUND The purpose of this retrospective study was to evaluate the results of the Eurotransplant Senior Programme (ESP) within our centre compared to elderly recipients >or=60 years from the regular Eurotransplant Kidney Allocation System (ETKAS), specifically focusing on surgical aspects. METHODS Data from 73 ESP patients (average donor/recipient age: 71.1/67.1) were compared with those from 51 patients (49.7/63.6) treated within the framework of the ETKAS program between the years 1999 and 2006. The mean follow-up was 39.5 months. RESULTS Cold ischaemic time (ESP versus ETKAS: 10.3 versus 15.0 h), duration of renal replacement therapy (42.2 versus 76.8 months), donor glomerular filtration rate (81.7 versus 109.9 ml/min/1.73 m(2)) and HLA mismatches (4.1 versus 2.4) were significantly different between the two groups (all P < 0.001). Primary graft function was seen in 74% ESP versus 69% of ETKAS patients (P > 0.05). The rate of surgical complications in the ESP versus ETKAS group was 47% versus 28% (P = 0.031) and the revision rate, 33% versus 24% (P = 0.259). Three-year patient and censored graft survival was 84% versus 92% and 85% versus 88% in the ESP and ETKAS group, respectively (all P > 0.05). Ninety-five percent of all deceased patients died with a functioning graft. CONCLUSIONS The donor and recipient pool has been markedly expanded through ESP with similar patient and graft survival compared to elderly recipients grafted according to ETKAS criteria. However, patients and their physicians should be aware of the high surgical complication rate in elderly recipients, particularly when receiving elderly donor kidneys. This might seriously influence postoperative patient management but ultimately does not compromise the transplant outcome.

De novo renal cell carcinoma of native and graft kidneys in renal transplant recipients

Study Type – Therapy (case series)

Development of urological cancers in renal transplant recipients: 30‐year experience at the Frankfurt Transplant Center

Fatal post‐transplant malignancies with a high proportion of genitourinary neoplasms represent a serious long‐term challenge. With continuous improvement of the allograft and patient survival, cancer development after renal transplantation may soon turn to the leading morbidity cause. In a retrospective single‐center study of 1990 renal transplant recipients between November 1979 and November 2009, records of patients with urological neoplasms including epidemiological, clinical and survival parameters were accessed. Sixty‐six de novo urological malignancies in 58 recipients were recorded in the study period, being most common after skin cancers (15.6% of enregistered tumors). From these, 29 were renal cell cancers, including five neoplasms of transplanted kidney, 24 transitional cell carcinomas, 11 prostate carcinomas, and two germ cell carcinomas with incidence rates of 1.5%, 1.2%, 0.9% and 0.2%, respectively. The patient follow up was virtually complete. Tumor‐related death was found in 44% of cases. By multivariate analysis, no influence of either duration of dialysis, mode or duration of immunosuppression, gender or age at transplantation on overall patient survival could be demonstrated. This study, documenting a 30‐year single center experience, emphasizes the increased risk for urological neoplasms occuring after renal transplantation. Screening strategies for urological cancers should be optimized. (Cancer Sci 2010; 101: 2430–2435)

Roboterunterstützte Laparoskopie in der UrologieRadikale Prostatektomie und rekonstruktive retroperitoneale Eingriffe

ZusammenfassungKomplexe rekonstruktive laparoskopische Operationen auf dem Gebiet der Urologie haben in den letzten 2 Jahren zunehmende Aufmerksamkeit erfahren. Zur Beherrschung dieser Operationstechniken ist jedoch ausgiebige laparoskopische Erfahrung erforderlich. Aus diesem Grunde ist es fraglich, ob diese Techniken, die sich in der Hand des Spezialisten als vorteilhaft für den Patienten erwiesen haben, ausreichende klinische Verbreitung finden.Wir haben die moderne Computertechnologie genutzt, um die Diskrepanz zwischen offener Chirurgie und laparoskopischem Zugang zu überbrücken und setzten das DaVinci-surgical-System ein, um in unserer Klinik die laparoskopische radikale Prostatektomie und die Pyeloplastik sowie andere retroperitoneale Eingriffe zu etablieren.Mit Hilfe des DaVinci-Systems kann sowohl die radikale Prostatektomie als auch retroperitoneale Eingriffe einfach und mit rascherer Lernkurve von der offenen Technik in laparoskopische Operationen übersetzt werden.Es ist zu erwarten, dass in der Zukunft der urologischen Chirurgie große Schnitte ein Relikt der Vergangenheit sein werden. Der technische Fortschritt wird uns in die Lage versetzen, bessere operative Resultate trotz minimaler Invasivität zu erreichen.AbstractComplex reconstructive laparoscopic procedures in the field of urology such as radical prostatectomy and pyeloplasty have attrac-ted increased attention in the past 2 years. However, extensive laparoscopic experience is required to master these procedures. Therefore, it remains questionable whether these techniques, which have been shown to be of profit to the patient in the hands of a specialist, will achieve widespread distribution.We have employed computer techno-logy to bridge the gap between open surgery and laparoscopic access and used the daVinci® Surgical System to establish laparoscopic radical prostatectomy as well as pyeloplasty and other retroperitoneal procedures at our institution.With experience of more than 70 procedures, we find that with the assistance of the daVinci Surgical System both radical prostatectomy and retroperiteoneal procedures can be easily translated from open to minimally invasive procedures with a considerably shorter learning curve and without compromising patient safety.We expect that large incisions will be soon a thing of the past in urologic surgery. Computer technology, together with mechanical engineering, will play a major role in enabling us to achieve better results despite minimal invasiveness.

Qualität der Leichennierenentnahme in Deutschland

ZusammenfassungHintergrundOrganverletzungen im Rahmen der Organentnahme werden von vielen Transplantationszentren zunehmend als Problem empfunden, wobei publizierte Daten kaum vorliegen. Ziel der vorliegenden Arbeit war es, die Qualität der Leichennierenentnahme in Deutschland zu untersuchen.Material und MethodenAlle an unserer Klinik zwischen 1996 und 2005 durchgeführten allogenen Leichennierentransplantationen mit einem innerhalb Deutschlands entnommenen und von Eurotransplant vermittelten Organ wurden retrospektiv aufgearbeitet.ErgebnisseVon insgesamt 486 entnommenen Leichennieren wurden 103 (21,2%) von den Transplanteuren beanstandet. Keines der Organe musste abgelehnt werden. Bei 18 (3,7%) Transplantationen war die mangelhafte Entnahme mit einer erheblichen Ausweitung des Eingriffs bzw. Komplikationen verbunden.SchlussfolgerungEine mangelhafte Organentnahme geht selten mit klinischen Konsequenzen einher. Trotzdem ist eine intensivere Schulung der entnehmenden Operateure unerlässlich. Ob die von der Bundesärztekammer seit dem 01.01.2006 geforderten 10 Nierenentnahmen unter Anleitung vor selbständiger Entnahme ausreichen, bleibt abzuwarten. Eine zusätzliche klinikübergreifende Fortbildung wäre wünschenswert.AbstractBackgroundOrgan damage during organ procurement is believed to be an increasing problem among transplant centres. However, only very few published data are available. The purpose of our study was to examine the quality of kidney procurement in Germany.MethodsWe retrospectively analyzed all allograft renal transplants performed at our centre from 1996 to 2005. All kidneys were retrieved in Germany and allocated by Eurotransplant.ResultsFrom a total of 486 cadaveric kidneys, 103 (21.2%) were not correctly retrieved. Nevertheless, none of the organs had to be rejected. In 18 (3.7%), a technically insufficient organ retrieval was associated with a considerable extension of the surgical procedure or complications.ConclusionsTechnically insufficient kidney procurement rarely results in clinical consequences. However, surgeons performing organ retrieval should be better trained. Whether adequate technical proficiency is achieved with ten supervised cases, as requested by the German Medical Association, remains to be determined. In our opinion, a further interdisciplinary course that trains surgeons in more refined techniques of organ procurement is desirable.

Quality of kidney procurement in Germany. Ten years experience and 486 renal allografts in a single centre

ZusammenfassungHintergrundOrganverletzungen im Rahmen der Organentnahme werden von vielen Transplantationszentren zunehmend als Problem empfunden, wobei publizierte Daten kaum vorliegen. Ziel der vorliegenden Arbeit war es, die Qualität der Leichennierenentnahme in Deutschland zu untersuchen.Material und MethodenAlle an unserer Klinik zwischen 1996 und 2005 durchgeführten allogenen Leichennierentransplantationen mit einem innerhalb Deutschlands entnommenen und von Eurotransplant vermittelten Organ wurden retrospektiv aufgearbeitet.ErgebnisseVon insgesamt 486 entnommenen Leichennieren wurden 103 (21,2%) von den Transplanteuren beanstandet. Keines der Organe musste abgelehnt werden. Bei 18 (3,7%) Transplantationen war die mangelhafte Entnahme mit einer erheblichen Ausweitung des Eingriffs bzw. Komplikationen verbunden.SchlussfolgerungEine mangelhafte Organentnahme geht selten mit klinischen Konsequenzen einher. Trotzdem ist eine intensivere Schulung der entnehmenden Operateure unerlässlich. Ob die von der Bundesärztekammer seit dem 01.01.2006 geforderten 10 Nierenentnahmen unter Anleitung vor selbständiger Entnahme ausreichen, bleibt abzuwarten. Eine zusätzliche klinikübergreifende Fortbildung wäre wünschenswert.AbstractBackgroundOrgan damage during organ procurement is believed to be an increasing problem among transplant centres. However, only very few published data are available. The purpose of our study was to examine the quality of kidney procurement in Germany.MethodsWe retrospectively analyzed all allograft renal transplants performed at our centre from 1996 to 2005. All kidneys were retrieved in Germany and allocated by Eurotransplant.ResultsFrom a total of 486 cadaveric kidneys, 103 (21.2%) were not correctly retrieved. Nevertheless, none of the organs had to be rejected. In 18 (3.7%), a technically insufficient organ retrieval was associated with a considerable extension of the surgical procedure or complications.ConclusionsTechnically insufficient kidney procurement rarely results in clinical consequences. However, surgeons performing organ retrieval should be better trained. Whether adequate technical proficiency is achieved with ten supervised cases, as requested by the German Medical Association, remains to be determined. In our opinion, a further interdisciplinary course that trains surgeons in more refined techniques of organ procurement is desirable.

Effect of procurement‐related organ lesions on renal transplant outcome

Abstract: Background:  The purpose of our study was to examine the nature and incidence of renal injuries during organ procurement, to identify risk factors and to analyse the effects of organ lesions on the following transplantation.

An Easy Method To Localize The Vesical Opening Of An Enterovesical Fistula

Enterovesical fistulas develop most often in connection with diverticulitis, Crohn’s disease and therapeutic radiation, and as a complication of anal surgery.1 While the existence of an enterovesical fistula is obvious when symptoms such as pneumaturia and fecal material in the urine are present, localization of the fistula is sometimes more complicated. To plan appropriate surgical treatment it is of the utmost importance to localize the opening of the fistula. We report the detection of the vesical opening of an enterovesical fistula in a patient in whom computerized tomography, magnetic resonance imaging, cystoscopy, urography and cystography failed to localize the fistula.