Nikolaus T. Schmeller

Endoscopic Vaporesection of the Prostate Using the Continuous-Wave 2-μm Thulium Laser: Outcome and Demonstration of the Surgical Technique

BACKGROUND The potential of a new continuous-wave (CW) 70-W, 2.013-microm thulium-doped yttrium aluminium garnet (Tm:YAG) laser for the endoscopic treatment of benign prostatic hyperplasia (BPH) is investigated. OBJECTIVE The simultaneous combination of vaporisation and resection of prostatic tissue in a retrograde fashion is the main characteristic of this new laser technique. We provide a DVD that shows the main steps of this procedure. DESIGN, SETTING, AND PARTICIPANTS We retrospectively evaluated 56 nonconsecutive patients who were treated by thulium laser vaporesection of the prostate in our institution between 2005 and 2007. SURGICAL PROCEDURE Vaporesection of the prostate is performed by moving the fibre semicircumferentially from the verumontanum towards the bladder neck, thereby undermining tissue and cutting chips. MEASUREMENTS Blood loss, postvoiding residual urine (PVRU), maximum flow rate (Q(max)), and the International Prostate Symptom Score (IPSS) were measured as well as prostate volume and prostate-specific antigen (PSA). The duration of the procedure, need for postoperative irrigation, duration of catheterisation, and hospital stay were recorded. RESULTS AND LIMITATIONS The median procedure time was 60 min, postoperative irrigation was necessary in 19 out of 56 patients, and the median duration of catheterisation was 23 hr. At the day of discharge, the mean haemoglobin value decreased by 0.2mg/dl (p=0.13), the average Q(max) improved from 8.1 to 19.3 ml/s (p<0.001), and the PVRU decreased from 152 ml to 57 ml (p<0.05). The blood transfusion rate was 3.6%, and two patients needed a recatheterisation postoperatively (3.6%). After a median follow-up of 9 mo, the IPSS improved from 19.8 at baseline to 8.6 (p<0.001). Four patients had a repeat transurethral resection of the prostate (TURP) during the learning curve, but this was not necessary in any of the later patients. One patient developed a urethral stricture, and another developed a bladder neck contracture. CONCLUSIONS The thulium laser seems to be a suitable tool for the endoscopic treatment of BPH.

Head‐to‐head comparison of retropubic, perineal and laparoscopic radical prostatectomy

Objective:  As more patients are diagnosed with prostate cancer at an early stage, it is becoming increasingly important to refine the technique of surgical excision. For this purpose we have generated objective data comparing three different surgical approaches used by three experienced surgeons.

Prostate Biopsy in Central Europe: Results of a Survey of Indication, Patient Preparation and Biopsy Technique

Objective: We surveyed urologists in Austria, Germany and Switzerland regarding their standard approach to prostate biopsy. Methods: Participants of Austrian and German urological meetings were asked to fill out a survey form; additionally, this was mailed to all Swiss urologists. Results: 304 surveys are available for analysis. 97% of participants perform a biopsy if digital rectal examination is abnormal. 63% use 4 ng/ml PSA (prostate-specific antigen) as cut-off. Age-related reference ranges are used by 54%, free PSA by 57%. 22% use PSA density, 55% PSA velocity. Overall 61% require a written consent, with 85, 86 and 25% in Austria, Germany and Switzerland. 96% of the urologists prescribe a quinolone antibiotic with a wide range regarding the start and end of drug therapy. 77% offer some kind of anaesthesia. Periprostatic injection of a local anaesthetic drug is used by 36%, lidocaine gel by 27%. 91% perform the biopsies transrectally under ultrasound guidance. Digitally guided biopsies are used by 11%. Only 3 participants perform perineal biopsies. The mean number of cores per biopsy session is 9.2, the maximum number of cores is 15.3 as a mean. Participants will stop performing any further biopsies if the patient already had a mean of 3.5 biopsy sessions. Conclusions: The majority of urologists in Central Europe prescribe a quinolone antibiotic and recommend some type of analgesia. The majority has abandoned the sextant technique and increases the number of cores in the case of rebiopsy. Biopsies are stopped after a mean of 3.5 sessions.

The use of Duloxetine in the treatment of male stress urinary incontinence

ZusammenfassungBelastungsinkontinenz kann Folge chirurgischer Eingriffen an der Prostata sein. Bis jetzt gibt es hierfür keine etablierte medikamentöse Therapie. Aktuell ist Duloxetin, ein Serotonin und Norepinephrin Wiederaufnahmehemmer zur Therapie der Belastungsinkontinenz der Frau zugelassen. Die vorliegende Studie beschreibt die Wirkung bei Männern mit Belastungsinkontinenz nach radikaler Prostatektomie oder transurethraler Elektroresektion. 56 Patienten wurden in unsere Analyse aufgenommen, 49 nach radikale Prostatektomie und 7 nach transurethrale Elektroresektion. Alle Patienten erhielten initial ein Beckenbodentraining. Bei ausbleibendem Erfolg verabreichten wir 2 × 40 mg Duloxetin. Unter Duloxetin reduzierte sich der Verbrauch an Inkontinenzvorlagen von 3,3 auf 1,5 pro Tag. 14 Patienten verwendeten keine und 18 nur mehr eine Vorlage pro Tag. Die meisten Patienten berichteten von milden Nebenwirkungen welche nach einigen Wochen vergingen. 13 bezeichneten ihre Nebenwirkungen als moderat und 9 als stark. Das Ergebnis dieser Anwendungsstudie zeigt, dass Duloxetin effektiv bei Belastungsinkontinenz nach Prostataoperationen verwendet werden kann, auch wenn ein gezieltes Beckenbodentraining keinen Erfolg brachte.SummaryStress urinary incontinence (SUI) is a known complication after prostate surgery. To date no pharmacologic treatment is available. Currently Duloxetine, a serotonin and norepinephrine reuptake inhibitor, is available for women with SUI. This study investigates the effect of Duloxetine on men with SUI after prostate surgery. 56 patients were included in our study. 49 after radical prostatectomy and 7 after TURP. All patients were initially treated with pelvic floor exercises. Thereafter 40 mg Duloxetine was administered twice daily. When taking Duloxetine, the average use of incontinence pads decreased from 3.3 to 1.5 per day. 14 patients needed no and 18 a single pad per day. Most patients reported mild and temporary side effects, 13 patients assessed them to be moderate and 9 being severe. The results of this off-label use show that Duloxetine is effective in men with SUI after prostate surgery even if standard pelvic floor exercises have failed.

Comparison of Lidocaine Suppositories and Periprostatic Nerve Block during Transrectal Prostate Biopsy

The aim of this randomized prospective and partially double-blind study was to evaluate the efficacy of transrectal lidocaine applied as suppositories in comparison to periprostatic infiltration as methods of reducing pain during transrectal prostate biopsy. 100 patients were randomized to four groups and received either a suppository containing 60 mg of lidocaine 2 h before biopsy, a 120-mg lidocaine suppository 1 h before biopsy, a 120-mg lidocaine suppository 2 h before biopsy, or they were anaesthetized with a periprostatic infiltration of 5 ml 2% lidocaine. In all patients the same 10-core transrectal biopsy technique was performed. Pain was evaluated using a visual pain scale ranging from 0 to 10 points. The mean pain score in the 60-mg (2 h), 120-mg (1 h), and 120-mg (2 h) lidocaine suppository groups was 3.63, 3.56, and 3.58 respectively. The mean pain score of patients receiving periprostatic infiltration was 1.80. No patient showed vegetative symptoms like sweating or hypotonia. No patient had severe pain. Eight of the 9 patients with no pain were in the periprostatic injection group. Thus, all lidocaine suppositories showed a good analgesic effect although a significantly better pain reduction was achieved by periprostatic lidocaine infiltration.

Use of veno-venous bypass for resection of malignant pheochromocytoma with vena caval thrombus.

Surgical management of malignant pheochromocytoma with tumor-induced venous obstruction involving the entrance to the right atrium is challenging. The risk of marked hypotension and hemodynamic instability following clamping of the vena cava is increased as a consequence of the sudden decrease in circulating catecholamines. The use of cardiac bypass, however is burdened with additional operating time and coagulopathy. The present report illustrates that veno-venous bypass is a valuable tool during resection of phenochromocytoma with a large vena caval tumor thrombus.

Anatomical Considerations in Suprahilar Lymph Node Dissection for Testicular Tumors

To evaluate the usefulness of removing lymph nodes located above the renal vessels in men with nonseminomatous testicular cancer we have: (1) reviewed the anatomy of the testicular lymphatic drainage; (2) analyzed data on 30 suprahilar lymph node dissections, and (3) reviewed 19 CT scans on patients with testicular cancer. Because the primary lymphatic drainage of the testis is not to suprahilar nodes, in the absence of bulky disease these lymph nodes rarely contain metastatic disease. Furthermore, because most suprahilar lymph nodes are located behind the aorta in between the crura of the diaphragm these lymph nodes are difficult, if not impossible, to resect. Thus, in patients without lymph node enlargement, suprahilar extension of routine lymphadenectomies is not recommended.

Trifurcation of the Urethra: A Case Report

Abstract We report a case of trifurcation of the prostatic urethra with congenital absence of the right kidney and testicle.