Othmar Seemann

Heilbronn Laparoscopic Radical Prostatectomy

Introduction: In 1999, Guillonneau and Vallancien presented a refined approach of a descending laparoscopic radical prostatectomy which based mainly on the primary access to the seminal vesicles and an improved suturing and knotting technique. Based on our own experience reconstructive laparoscopy as well as with open retropubic radical prostatectomy we have used a combined ascending/descending technique similar to open surgery. In this paper we want to describe our approach and to present the initial results with the Heilbronn technique. Materials and Methods: A transperitoneal approach is used with a W–shaped arrangement of the trocars (13–mm umbilical port, 2×10 mm medial, 2×5 mm lateral ports). After the exposure of the Retzius’ space and control of the dorsal vein complex the urethra is incised and the distal pedicles of the prostate (± the neurovascular bundle) are transsected. We now pull the apex ventrally and start with the incision at the bladder neck followed by a transvesical access to both vasa deferentia and seminal vesicles. The gland is entrapped in the Extraction Bag®. After accomplishing the posterior wall of the urethrovesical anastomosis with five interrupted sutures, the foley catheter is placed into the bladder and the bladder neck is closed. Now the prostate is extracted via the umbilical incision. From March 1999 to June 2000, we have performed 100 cases (48 pT2–, 47 pT3– and 5 pT4 tumors). The mean preoperative PSA was 26.8 (1.4–75.5) ng/ml. Two tumors were grade 1, 72 grade 2 and 26 grade 3. Median Gleason score was 6 (3–9). All specimen were inked and examined according to the Stanford protocol. Postoperative continence was evaluated using a questionnaire monitored by a colleague who was involved in surgery. Results: We had 5 conversions (rectal injury, difficult dissection, adhesion, 2× bleeding at the dorsal vein complex). The mean operating time was 278 (180–500) min., the transfusion rate 31%. One patient required reintervention due to bleeding from the right obturator fossa. 95% of the patients did not require any analgesia on the second postoperative day. Positive margins were found in 17% of the patients, of which 12 had a PSA nadir to a value of less than 0.1 ng/ml within 3 weeks after surgery. In 82 patients, the anastomosis was tight after removal of the catheter, median catheter time was 8 (6–30) days. 4% developed a stricture at the anastomotic site which could be treated by laserincision. On discharge 33% were continent, after 6 months 81%, whereas only 2 patients still suffer from grade II stress incontinence at 9 months. Conclusions: Laparoscopic radical prostatectomy is feasable but requires laparoscopic expertise. Its learning curve is still ongoing. Morbidity is low, oncological control is similar to results of open surgery, functional results are promising.

Laparoscopic radical prostatectomy: functional and oncological outcomes.

Purpose of review Laparoscopic radical prostatectomy has become an accepted alternative to open surgery, however data on the functional and oncological outcome are still lacking. In this study we present an analysis based on a survey of the current literature and the first 500 patients treated with the Heilbronn technique. Additionally, we compare the results of laparoscopy with those of open radical prostatectomy. Recent findings We conducted an extensive MEDLINE search of laparoscopic and open radical prostatectomy from 1999 through 2003, focusing on the last 3 years. The articles as well as our own results were analyzed with respect to continence, potency, positive margins, prostatic specific antigen failure, and clinical progression. No significant differences were found between the laparoscopic and open approach with respect to overall continence at 12 months (60-94% versus 61-98%) or at 3 months (51-63% versus 62-69%), varying from 4.1% at pT2, 12% at pT3 to 19% at pT4 stages. We found no significant differences between the two techniques in the recovery of potency (34-67% versus 31-79%), if one excludes the selected series of Walsh with a mean age of 57 years. Furthermore, we did not detect any significant differences in positive margins and short-term prostatic specific antigen recurrence (3 years). Summary At centers of expertise, laparoscopic radical prostatectomy is able to provide similar functional and oncological results as its open counterpart, however with the advantages of minimally invasive surgery.

Telesurgical laparoscopic radical prostatectomy. Initial experience.

Introduction: Telepresence surgery offers theoretically to overcome two main problems of laparoscopic surgery, i.e. the limitation to only four degrees of freedom and the lack of stereovision. Since 1998, telesurgical minimally invasive procedures have been performed with the da Vinci system mainly for cardiac bypass surgery. Clinical experience in urology is still very limited. We want to present our initial experience using the device for robot–assisted laparoscopic radical prostatectomy. Material and Methods: The Intuitive surgical system consists of two main components: the surgeon’s viewing and control console with 3D imaging and the surgical arm unit that positions and maneuvers detachable surgical instruments. These instruments introduced via two 8–mm trocars allow movements in all 6 degrees of freedom due to the EndoWrist technology. The surgeon performs the procedure seated at the console holding specially designed instruments. Highly specialized computer software and mechanics transfer the surgeon’s hand movements exactly to the microsurgical movements of the manipulators at the operative site. We have used a semilunar–shaped 5–trocar arrangement with the robot’s arms at the lateral trocars and two assistant trocars medially. A sixth trocar was used in the right suprapubic area for retraction of the gland. The left assistant used different instruments such as bipolar forceps, Ultracision, Endoclip, whereas the right assistant mainly used the suctcion–irrigation device. Except the first case, the Intuitive System was attached after exposure of Retzius’ space. Results: We have treated 6 patients (2 pT2, 4 pT3, median Gleason score 6). The OR time averaged 315 (242–480) min including pelvic lymph node dissection. No intraoperative complications occurred, 1 patient required transfusions. There were no positive margins, median catheter time was 5 days. 3 patients were completely continent after 1 month. Conclusion: Telerobotic laparoscopic surgery offers several advantages over all presently available techniques, such as all six degrees of freedom, dexterity enhancement, tremor filtering, and stereovision. There is a learning curve with the device, mainly because of the magnification, the 3D image and the lack of tactile feedback. However, only after a short period of time, the experienced surgeon is able to get familiar with the device. However, there are still concerns with respect to the high investment and running costs of the device as well as regarding the necessitity of further developments of instruments for urological procedures.

Comparison of urodynamic findings and response to oxybutynin in nocturnal enuresis.

Sixty-three children with persistent nocturnal enuresis were urodynamically assessed and subsequently treated with oxybutynin chloride. Urodynamic evaluation, including graduation of detrusor instability and comparison of maximum bladder capacity with the age-predicted norm, confirmed an inadequate storage function in 84% of the children. Treatment benefit totaling 70% was dependent upon urodynamic findings, with best relation to the determined bladder capacity. The value attributed to graduation of uninhibited contractions was prognostic in accordance with further subdivision of the maximum bladder capacity. Treatment benefit was limited in children with normal urodynamic findings.

Cisplatin-resistant bladder carcinoma cells: enhanced expression of metallothioneins.

Abstract Cisplatin is one of the most potent cytotoxic drugs and in chemotherapy has ameliorated numerous tumors. Nevertheless, resistance to cisplatin is a problem that is encountered in the chemotherapy of urologic tumors, especially transitional cell carcinomas. In order to improve definition of the mechanisms of cisplatin-resistance we established a series of cisplatin-resistant sublines from the cell line RT 112 in increasing concentrations of cisplatin. The most resistant subline CP3 is approximately 10 times more resistant than the parental line and shows a 10-fold cross-resistance against methotrexate, whereas vinblastine and doxorubicin are equally effective in the parental and sublines. Combined treatment of CP3 cells with cisplatin and buthionine sulfoximine (BSO) does not result in enhanced cell kill, thereby ruling out glutathione as a resistance mechanism. However, in comparison with parental cells, CP3 cells are about 1.5 times more resistant against cadmium. On the protein level, the cisplatin-resistant cells reveal an enhanced expression of metallothionein II (MTII), but not MTI, suggesting that the cisplatin resistance we observed in these sublines is at least partly mediated by MTII. These sublines will in the future serve as valuable tools for the analysis of cisplatin resistance, especially in view of metallothionein-mediated resistance mechanisms.

Penile revascularization in nonresponders to intracavernous injections using a modified microsurgical technique

At certain centers, microsurgical penile revascularization, using different surgical techniques, has gained importance throughout the past years. In general, only patients classified as intracavernous injection nonresponders are subjected to this kind of surgery. Since 1988, revascularization surgery has been performed at our clinic on 19 intracavernous injection nonresponders. The Hauri technique was carried out on the first 6 patients. The last 10 patients underwent modified anastomosis surgery. The inferior epigastric artery and the dorsal penile artery are anastomosed, one behind the other, end-to-side, to the dorsal penile vein. This results in a more simple procedure with assurance of flow. The Virag technique was performed on 3 patients. 18 patients achieved erections with or without the aid of intracavernous injections (at a mean follow-up of 13.4 months). 11 patients were capable of spontaneous erections, whereby it was particularly noted that 8 of the 10 patients undergoing the modified technique achieved spontaneous erections. The results demonstrate that intracavernous injection nonresponders benefit from revascularization surgery.

Retroperitoneal laparoscopic nephropexy

Laparoscopic nephropexy is a suitable and clinically established procedure for the treatment of symptomatic nephroptosis. The availability of a minimally invasive therapy can facilitate decisions regarding the indication after careful selection of patients.

Development, Validation and Operating Room-Transfer of a Six-Step Laparoscopic Training Program for the Vesicourethral Anastomosis

PURPOSE Development and full validation of a laparoscopic training program for stepwise learning of a reproducible application of a standardized laparoscopic anastomosis technique and integration into the clinical course. MATERIALS AND METHODS The training of vesicourethral anastomosis (VUA) was divided into six simple standardized steps. To fix the objective criteria, four experienced surgeons performed the stepwise training protocol. Thirty-eight participants with no previous laparoscopic experience were investigated in their training performance. The times needed to manage each training step and the total training time were recorded. The integration into the clinical course was investigated. The training results and the corresponding steps during laparoscopic radical prostatectomy (LRP) were analyzed. Data analysis of corresponding operating room (OR) sections of 793 LRP was performed. Based on the validity, criteria were determined. RESULTS In the laboratory section, a significant reduction of OR time for every step was seen in all participants. Coordination: 62%; longitudinal incision: 52%; inverted U-shape incision: 43%; plexus: 47%. Anastomosis catheter model: 38%. VUA: 38%. The laboratory section required a total time of 29 hours (minimum: 16 hours; maximum: 42 hours). All participants had shorter execution times in the laboratory than under real conditions. The best match was found within the VUA model. To perform an anastomosis under real conditions, 25% more time was needed. By using the training protocol, the performance of the VUA is comparable to that of an surgeon with experience of about 50 laparoscopic VUA. Data analysis proved content, construct, and prognostic validity. CONCLUSIONS The use of stepwise training approaches enables a surgeon to learn and reproduce complex reconstructive surgical tasks: eg, the VUA in a safe environment. The validity of the designed system is given at all levels and should be used as a standard in the clinical surgical training in laparoscopic reconstructive urology.

Establishment and characterization of a multidrug-resistant human bladder carcinoma cell line RT112/D21

A doxorubicin-resistant human bladder carcinoma cell line RT112/D21 was established by continuous exposure of the parental line RT112 to increasing concentrations of doxorubicin over a period of 9 months. RT112/D21 cells expressed significantly more P-170 glycoprotein than the parental line, and rhodamine 123 efflux, as a functional parameter of P-170 glycoprotein activity, was increased. RT112/D21 cells were 96 times more resistant to doxorubicin than RT112 cells, and crossresistance to epirubicin and vinblastine was present. Sensitivity to methotrexate and mitomycin C remained unchanged. R-verapamil reversed resistance to doxorubicin, epirubicin and vinblastine in RT112/D21 cells but did not affect sensitivity to methotrexate and mitomycin C. In RT112 cells, R-verapamil had no effect on drug sensitivity. Thus, it may be assumed that primary or induced MDR1 gene-encoded P-170 glycoprotein expression is a relevant mechanism of chemoresistance in transitional cell carcinoma, and that chemotherapeutic strategies in combination with chemosensitizers improve response rates.

Bladder neck suspension techniques with osseous screw fixation

SummaryWe investigated the technical feasibility and clinical results of bone fixation techniques in combination with needle suspension for correction of female stress urinary incontinence. In our experience the screw-like bone anchor, which is drilled into the pubic tubercle, represents a minimally invasive but very stable and reliable technique. However, the needle suspension fixed to the bone anchor turned out to be critical. Even though the suspension was fixed in the paraurethral tissue with a deep Z-stitch between the bladder neck and the midurethra, the 1-year recurrence rate was 76 %. Our data showed that the suspension sutures pull through the paraurethral tissue because there is no paravesical scar formation as in open procedures. Modifications of the suspension technique (four-point suspension, simultaneous laparoscopic or digital dissection of the paravesical space, combination with sling procedures) revealed significantly improved short-term results. Therefore we conclude that after improvement of the suspension technique the bone anchor will represent a valid option for minimally invasive fixation of a bladder neck suspension.ZusammenfassungIn dem vorliegenden Artikel wird über technische Handhabung und klinische Ergebnisse der ossären Schraubenfixation in Kombination mit einer Blasenhalsnadelsuspensionsplastik berichtet. Die Ankerschraube stellt nach unseren Erfahrungen eine stabile und zuverlässige Aufhängung dar, die mit minimalem Operationstrauma in das Tuberculum pubicum eingebracht werden kann. Als problematisch hat sich ausschließlich die daran fixierte minimal invasive Blasenhalssuspension erwiesen. Trotz einer breiten, allschichtigen Fixation der Naht im Bereich zwischen Blasenhalswinkel und mittlerer Urethra trat nach einem Jahr in bis zu 76 % ein Rezidiv auf. Ursächlich dafür ist in erster Linie ein Durchwandern der Suspensionsnaht, da die zusätzliche Haltefunktion durch Vernarbung des Paravesikalraums wie nach offener Korrektur ausbleibt. Modifikationen der Suspension in dieser Hinsicht (4-Punkt-Aufhängung, simultane laparoskopische oder digitale Entwicklung des Spatium retzii, evtl. Kombination mit Schlingentechnik) ergaben deutlich bessere Ergebnisse. Wir gehen davon aus, daß nach Optimierung der Suspensionstechnik die ossäre Schraubenfixation eine valide Option zur Verankerung bietet.