Serdar Deger

LAPAROSCOPIC RADICAL CYSTECTOMY WITH CONTINENT URINARY DIVERSION (RECTAL SIGMOID POUCH) PERFORMED COMPLETELY INTRACORPOREALLY: THE INITIAL 5 CASES

PURPOSE We present our experience with the first 5 patients who underwent radical cystectomy with bilateral pelvic lymphadenectomy and continent urinary diversion (rectal sigmoid pouch) performed with an intracorporeal laparoscopic technique at our center. MATERIALS AND METHODS There were 3 males and 2 females 59 to 65 years old with organ confined, muscle invasive transitional cell carcinoma of the bladder who underwent surgery. The procedure included pelvic lymph node dissection, radical cystectomy with prostate or uterus and tubal structures, creation of the rectal sigmoid pouch and bilateral stented antireflux implantation of the ureters into the pouch. Freehand laparoscopic suturing and in situ knot tying techniques were used exclusively. The mobilized specimens were removed in an endoscopy bag via the rectum or vagina. Laparotomy was not required. RESULTS Operating time was 6.9 to 7.9 hours (median 7.4) and blood loss was 190 to 300 ml. (median 245). None of the 5 patients none needed blood transfusion. Oral intake was started on hospital day 3, ureteral stents were removed on day 8 and the pouch catheter was removed on day 9. The hospital stay was 10 days for all cases. Histopathological examination of the specimens revealed stage pT1 G3 urothelial carcinoma in case 1, pT2b G2 in cases 2 and 3, pT3a G2 in case 4 and pT3aG3 in case 5. The lymph nodes and resection margins were tumor-free. No intraoperative or postoperative complications were observed. CONCLUSIONS To our knowledge, this is the first series of laparoscopic radical cystectomy with intracorporeal continent urinary diversion (rectal sigmoid pouch), and our results are promising. With more experience and improvement of the surgical technique, laparoscopic radical cystectomy with continent urinary diversion may become an alternative surgical method for treating select patients with localized muscle invasive bladder cancer.

Laparoscopic Radical Prostatectomy

Purpose: The laparoscopic access for radical prostatectomy offeres an alternative to the open surgical procedure with less morbidity. We report on our experience with 125 laparoscopic prostatectomies, especially with respect to making the laparoscopic approach a routine procedure and with a view to the oncological and functional results. Material and Methods: From June 1999 to September 2000, we performed 125 laparoscopic prostatectomies. These included only patients with cancer stages T1 or T2. The mean PSA concentration was 10.5 ng/ml. Forty–four percent of the patients had undergone previous abdominal and 19% previous transurethral surgery. For our laparoscopic prostatectomies we used the descending technique. Free–hand laparoscopic suturing and in situ knot–tying technique were used for the urethrovesical anastomosis. The mobilized specimens were removed in an endobag via a muscle splitting incision. Results: All 125 procedures could be completed successfully. No case required conversion to open surgery. The average operating time was 255 min, the last 40 procedures taking 200 min only. Mean blood loss was 185 ml. Two patients (2%) required postoperative blood transfusion. After an initial learning curve, catheter remained in place for an average of 5.5 days, and the average postoperative stay in hospital was 8 days. Intraoperative complications were seen in 5 patients (4%). In 13 patients (10.4%) postoperative complications were observed. 86% of the patients are continent 6 months postoperatively. Preservation of the neurovascular bundle and sexual potency is possible. Conclusion: Laparoscopic radical prostatectomy is an ambitious procedure with a steep learning curve, especially for the laparoscopic dissecting and suturing technique. The excellent sight for dissection results in a reduced blood loss and faster convalescence with an overall lower morbidity. Also with regard to oncological and functional (continence) results the minimally invasive access is at least equivalent to the open procedure. In our opinion, laparoscopic prostatectomy will be the future method of choice for radical prostatectomy.

Quality of life of living kidney donors in Germany: a survey with the Validated Short Form-36 and Giessen Subjective Complaints List-24 questionnaires.

Background. Most studies evaluating the impact of kidney donation on donors’ quality of life (QOL) have limitations such as small cohort size, unmatched references, use of nonstandardized and nonvalidated questionnaires, or low response rates. Methods. We performed a study on donors’ QOL that was designed to avoid these limitations. All available living renal donors in our department in the last 18 years were included in the study. QOL was assessed with two validated, standardized questionnaires (Short Form-36, Giessen Subjective Complaints List [Giessener Beschwerdebogen]-24) and compared with gender- and age-matched references. In addition, specific questions relating to kidney donation were asked. Results. The response rate (89.8%) is one of the highest reported for studies on QOL of living kidney donors. Most donors had an equal or better QOL than the healthy population. Donors’ willingness to donate again (93.4%) or recommend living-donor kidney transplantation (92.4%) was high, irrespective of complications. A small number of donors experienced financial drawbacks or occupational disadvantages. Donors aged 31 to 40 years were found to be at risk of QOL deterioration after organ donation. Donor and recipient complications had a significant impact on donors’ QOL. One third of the donors found that the psychologic care preceding and after kidney donation was insufficient. Conclusions. Our findings support the practice of living-donor kidney transplantation as a good means to meet the persisting organ shortage. Further effort must be put into minimizing donor and recipient complications. The specific demands of younger donors should be further elucidated. In addition to medical follow-up, living kidney donors should also be offered lifelong psychologic counseling.

Evaluation of Magnetic Fluid Hyperthermia in a Standard Rat Model of Prostate Cancer

PURPOSE To examine the feasibility and potential of magnetic fluid hyperthermia (MFH) as a minimally invasive method for hyperthermia treatment of prostate cancer. MATERIALS AND METHODS Orthotopic Dunning R3327 prostate tumors were induced in 20 male Copenhagen rats. The animals either received MFH treatment following intratumoral administration of magnetic fluids or were used as either tumor growth controls for determination of iron distribution in selected organs or as histologic controls without MFH treatment. The MFH treatments were carried out at 45 degrees C or 50 degrees C using an AC magnetic field applicator system designed for small animals. RESULTS Sequential treatments with MFH were possible following a single intratumoral injection of magnetic fluid. Intratumoral temperatures of 50 degrees C and more were obtained and were monitored online using fluoro-optic thermometry. Four days after MFH treatments, 79% of the injected dose of ferrites was still present in the prostate. CONCLUSIONS The successful intraprostatic nanoparticle infiltration and stable steady-state intratumoral treatment temperatures demonstrate the feasibility of MFH in a prostate cancer model. Efficacy and survival benefit must be confirmed in further experiments.

The new synthetic matrix metalloproteinase inhibitor (Roche 28-2653) reduces tumor growth and prolongs survival in a prostate cancer standard rat model.

The therapeutic efficacy of synthetic inhibitors of matrix-metalloproteinases (MMPs) in various cancers has been demonstrated. A novel inhibitor, Ro 28-2653, with high selectivity for MMP2, MMP9 and membrane type 1-MMP was evaluated in an orthotopic prostate cancer rat model. Efficacy was determined by recording tumor growth and survival endpoints. Prostate cancer was induced by inoculating R3327 Dunning tumor cells (MatLyLu) into the ventral lobe of the prostates of 148 Copenhagen rats. Daily oral treatment with Ro 28-2653 (10–300 mg/kg per day) was started on day 1 or on day 6 after tumor cell injection. Animals were sacrificed on day 20 for determination of tumor weights. For survival studies, rats received daily oral Ro 28-2653 (100 mg/kg per day) or vehicle for up to 30 days. Tumor induction was successful in 100% of the animals. Ro 28-2653 reproducibly reduced the tumor weights by up to 90% in a dose-dependent manner. In addition, an inhibitory effect in rats with established tumors (treatment start at day 6) was shown. A significantly prolonged survival of Ro 28-2653-treated rats was also demonstrated. Selective inhibition of MMP activity is a novel therapeutic approach, which bears promise for studies in patients with prostate cancer.

High Dose Rate Brachytherapy of Localized Prostate Cancer

Abstract Objective: We evaluated the safety and efficacy of high dose rate (HDR) brachytherapy using Iridium-192 (Ir 192) and 3D conformal external beam radiotherapy in patients with localized prostate cancer. Methods: A total of 444 patients with localized prostate cancer underwent combined radiotherapy with interstitial Ir 192 and 3D conformal external beam radiotherapy between December 1992 and March 2001. The 230 patients, treated between December 1992 and December 1997 were analyzed. All patients underwent laparoscopic pelvic lymph node dissection to exclude patients with lymphatic involvement. Ir 192 was delivered twice with a 1-week interval in HDR remote control technique. The interstitial dose from December 1992 to December 1993 was 10Gy, after December 1993 the dose was reduced to 9Gy per treatment session. The interstitial application was followed by external beam radiation of 45Gy for cT1–cT2 and 50.4Gy for cT3 tumor (40Gy from December 1992 to December 1993). Progression was defined as biochemical failure according to ASTRO criteria, e.g. three consecutive PSA rises following the PSA nadir. Results: The median PSA value decreased from 12.8 to 0.93ng/ml 12 months after treatment. Median PSA value was 0.47 after 24 months, 0.30ng/ml after 36 months and 0.18ng/ml after 60 months. 68% of the biopsies were negative 24 months after therapy. Progression-free rate was 100% for cT1 tumors, 75% for cT2 and 60% for stage-cT3 on 5-year follow-up. Five-year overall survival was 93%, 5-year disease-specific survival was 98%. Initial PSA value Conclusions: Combined HDR brachytherapy with Ir 192 is an alternative treatment option especially for patients with cT3 prostate cancer. Initial PSA value, stage and grade, are important prognostic factors.

Laparoscopic anatrophic nephrolithotomy

Management of staghorn calculi is still a challenge. To combine the surgical principles of treatment with the minimal invasive access we performed a laparoscopic anatrophic nephrolithotomy in a female patient successfully. Patient was discharged free of stone on fifth postoperative day. No complications occurred.

Gadolinium-enhanced three-dimensional magnetic resonance angiography versus conventional digital subtraction angiography: Which modality is superior in evaluating living kidney donors?

This study evaluates the correlation of magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) with the operative vessel findings in living kidney donors. The intraoperative vessel findings of 52 living renal donors were compared with the preoperative diagnoses of each imaging technique. Sixty-seven arteries were found during explantation. Forty kidneys showed a single arterial blood supply, and 12 kidneys showed a multiple arterial blood supply. No advantage of either imaging method was found for arterial imaging. There were 55 veins identified during organ harvesting. MRA could not determine the venous system in one donor (1.9%) and failed to detect one small pole vein in another. DSA did not yield a venous diagnosis in seven patients (13.5%) and yielded misdiagnoses in four patients. The correct diagnosis of renal donor veins differed significantly in favor of MRA (kappa 0.79 vs. 0.45; P=0.008). MRA is superior to DSA in assessing the renal vasculature in living kidney donors.

An artificial neural network for five different assay systems of prostate-specific antigen in prostate cancer diagnostics

To compare separate prostate‐specific antigen (PSA) assay‐specific artificial neural networks (ANN) for discrimination between patients with prostate cancer (PCa) and no evidence of malignancy (NEM).

Discordant total and free prostate-specific antigen (PSA) assays: does calibration with WHO reference materials diminish the problem?

Abstract Prostate-specific antigen (PSA) assay-dependent variations could result in misinterpretation of individual PSA values. Therefore, the situation for clinical interpretation of PSA or percent free PSA (%fPSA) results is complicated. This review summarizes the differences in various total PSA (tPSA) and free PSA (fPSA) assays, and results obtained using the new World Health Organization (WHO) calibrated Access assays from various studies. Method comparisons between the traditionally calibrated Hybritech PSA and fPSA assays and the new “standardized” WHO calibrated assays yield results that are ∼25% lower for PSA and fPSA. A PSA cut-off of 3 or 3.1 μg/L should be considered for WHO calibrated assays in order to achieve the same sensitivity/specificity profile as with a cut-off of 4 μg/L in traditionally calibrated assays. The %fPSA cut-offs could be retained. Clin Chem Lab Med 2009;47:1325–31.