U. Witzsch

180-W XPS GreenLight Laser Vaporisation Versus Transurethral Resection of the Prostate for the Treatment of Benign Prostatic Obstruction: 6-Month Safety and Efficacy Results of a European Multicentre Randomised Trial—The GOLIATH Study

BACKGROUNDnThe comparative outcome with GreenLight (GL) photoselective vaporisation of the prostate and transurethral resection of the prostate (TURP) in men with lower urinary tract symptoms due to benign prostatic obstruction (BPO) has been questioned.nnnOBJECTIVEnThe primary objective of the GOLIATH study was to evaluate the noninferiority of 180-W GL XPS (XPS) to TURP for International Prostate Symptom Score (IPSS) and maximum flow rate (Qmax) at 6 mo and the proportion of patients who were complication free.nnnDESIGN, SETTING, AND PARTICIPANTSnProspective randomised controlled trial at 29 centres in 9 European countries involving 281 patients with BPO.nnnINTERVENTIONn180-W GL XPS system or TURP.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnMeasurements used were IPSS, Qmax, prostate volume (PV), postvoid residual (PVR) and complications, perioperative parameters, and reintervention rates. Noninferiority was evaluated using one-sided tests at the 2.5% level of significance. The statistical significance of other comparisons was assessed at the (two-sided) 5% level.nnnRESULTS AND LIMITATIONSnThe study demonstrated the noninferiority of XPS to TURP for IPSS, Qmax, and complication-free proportion. PV and PVR were comparable between groups. Time until stable health status, length of catheterisation, and length of hospital stay were superior with XPS (p<0.001). Early reintervention rate within 30 d was three times higher after TURP (p=0.025); however, the overall postoperative reintervention rates were not significantly different between treatment arms. A limitation was the short follow-up.nnnCONCLUSIONSnXPS was shown to be noninferior (comparable) to TURP in terms of IPSS, Qmax, and proportion of patients free of complications. XPS results in a lower rate of early reinterventions but has a similar rate after 6 mo.nnnTRIAL REGISTRATIONnClinicalTrials.gov, identifier NCT01218672.

A comparison of urinary nuclear matrix protein-22 and bladder tumour antigen tests with voided urinary cytology in detecting and following bladder cancer:the prognostic value of false-positive results

Objectives To evaluate the diagnostic and prognostic value of the nuclear matrix protein‐22 (NMP22) and bladder tumour antigen (BTAstat) tests compared with voided urinary cytology (VUC) in detecting and following bladder cancer, assessing particularly the prognostic value of false‐positive test results in patients followed up for bladder cancer.

Quality of life after surgery for localized renal cell carcinoma: comparison between radical nephrectomy and nephron-sparing surgery

OBJECTIVESnTo compare the impact of radical nephrectomy and nephron-sparing surgery (NSS) for localized renal cell carcinoma on quality of life (QOL).nnnMETHODSnRetrospectively, 357 patients who had undergone NSS (n = 158) or radical nephrectomy (n = 199) for localized renal cell carcinoma completed postal questionnaires, including measures of QOL with validated instruments (SF-36, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 [EORTC QLQ-C30]), the impact of the stress of cancer, fear of recurrence, and worry about having fewer than two normal kidneys. A subset of 51 patients diagnosed after 2000 were followed up prospectively for at least 1 year.nnnRESULTSnThe mental and physical health composite scores were not significantly different from the validated norms for an age and sex-matched community sample. Although the type of operation had no influence on patients overall QOL, all patients who underwent elective NSS showed a significantly greater score on physical function than patients treated with radical nephrectomy (P <0.001). Predictors for higher scores included elective NSS, comorbidity (assessed with standardized checklist), tumor size, and time since nephrectomy. The overall QOL scores and recovery of stress from cancer in patients treated with NSS for tumor less than 4 cm with a normal contralateral kidney were significantly superior to those who underwent NSS for tumor greater than 4 cm (P <0.05). Patients questioned after mandatory NSS were significantly more concerned about cancer recurrence.nnnCONCLUSIONSnPatients without evidence of disease have relatively normal physical and mental health after operative treatment for localized renal cell carcinoma, independent of the kind of surgery. The QOL correlates proportionally with the size of tumor and is significantly better for patients undergoing NSS for tumor less than 4 cm with a normal contralateral kidney.

Birth of two infants with normal karyotype after intracytoplasmic injection of sperm obtained by testicular extraction from two men with nonmosaic Klinefelter’s syndrome

OBJECTIVEnTo report two births of a healthy male and a healthy female baby after use of testicular spermatozoa from two patients with nonmosaic Klinefelters syndrome.nnnDESIGNnCase report.nnnSETTINGnGeneral academic hospital with IVF center and university institute of human genetics.nnnPATIENT(S)nTwo couples with primary infertility in which the men had secretory azoospermia and nonmosaic 47,XXY karyotype. Both women had a normal karyotype and no gynecologic abnormalities.nnnINTERVENTION(S)nICSI was performed using testicular spermatozoa after ovarian stimulation and transvaginal ultrasonography-guided oocyte pick-up.nnnMAIN OUTCOME MEASURE(S)nNormal fertilization, embryo cleavage, clinical pregnancy outcome, and peripheral blood karyotype of the newborn.nnnRESULT(S)nIn each case, 13 metaphase II oocytes were injected, of which 7 fertilized normally. Three good-quality embryos (4-cell stage) were transferred into the uterine cavity. Both women conceived, and normal pregnancies followed. Genetic analysis of the neonates revealed normal 46,XX and 46,XY karyotypes.nnnCONCLUSION(S)nThese case reports reaffirm that patients with nonmosaic Klinefelters syndrome produce normal spermatozoa with fertilization potential. Although it is premature to make conclusions about the rate of transmission of this aneuploidy because of the low number of the published cases, this report substantiates the idea that rates of transmission of this gonosomal aneuploidy are low.

Preoperative neural network using combined magnetic resonance imaging variables, prostate-specific antigen, and Gleason score for predicting prostate cancer biochemical recurrence after radical prostatectomy

OBJECTIVESnTo develop and test an artificial neural network (ANN) for predicting biochemical recurrence based on the combined use of pelvic coil magnetic resonance imaging (pMRI), prostate-specific antigen (PSA) measurement, and biopsy Gleason score, after radical prostatectomy and to investigate whether it is more accurate than logistic regression analysis (LRA) in men with clinically localized prostate cancer.nnnMETHODSnWe evaluated 191 consecutive men who had undergone retropubic radical prostatectomy for clinically localized prostate cancer. None of the men had lymph node metastasis as determined by adequate follow-up and pathologic criteria. The preoperative predictive variables included clinical TNM stage, serum PSA level, biopsy Gleason score, and pMRI findings. The predicted result was biochemical failure (PSA level of 0.1 ng/mL or greater). The patient data were randomly split into four cross-validation sets and used to develop and validate the LRA and ANN models. The predictive ability of the ANN was compared with that of LRA, Han tables, and the Kattan nomogram using area under the receiver operating characteristic curve (AUROC) analysis.nnnRESULTSnOf the 191 patients, 57 (30%) developed disease progression at a median follow-up of 64 months (mean 61, range 2 to 86). Using all the input variables, the AUROC of the ANN was significantly greater (P <0.05) than the AUROC of LRA, Han tables, or the Kattan nomogram for the prediction of PSA recurrence 5 years after radical prostatectomy (0.897 +/- 0.063 versus 0.785 +/- 0.060, 0.733 +/- 0.061, and 0.737 +/- 0.071, respectively). Removing the pMRI findings from the previous models, the AUROC of the ANN decreased statistically significantly (P <0.05) and was comparable to the AUROC of conventional predictive tools (P >0.05).nnnCONCLUSIONSnUsing the pMRI findings, the ANN was superior to LRA, predictive tables, and nomograms to predict biochemical recurrence accurately. Confirmatory studies are warranted.

Cold-knife endoureterotomy for nonmalignant ureterointestinal anastomotic strictures

OBJECTIVESnTo evaluate the long-term results of cold-knife incision (CNI) of nonmalignant ureterointestinal anastomosis strictures (UASs) after urinary diversion in a consecutive series of patients.nnnMETHODSnSince 1994, we have evaluated retrospectively 40 patients with 43 UASs, who were primarily treated with CNI (group 1). Six patients from group 1 with 7 UASs who failed primary CNI comprised group 2. After placement of an 8F nephrostomy tube, a 0.035-inch guidewire bypassed the stricture in an antegrade fashion under guidance of a centrally opened ureteral catheter (5F). A wire-mounted cold-knife was pulled through the strictured area in retrograde fashion under fluoroscopic control. Postoperatively, an 8 to 12F stent was left indwelling for 6 to 12 weeks. Successful treatment was defined as radiographic and scintigraphic resolution of obstruction and symptomatic relief.nnnRESULTSnIn group 1, after removal of the stent, the ureteroenteric area remained patent in 26 (60.5%) of 43 UASs during a follow-up period of 38.8 months (range 12 to 85). The success rate at 1, 2, and 3 years was 86%, 67.8%, and 60.5%, respectively. In group 2, no success occurred. The diameter and length of the stricture, kidney function, hydronephrosis grade, presence of urinary infection at presentation, past CNI or radiotherapy, number of incisions with the cold-knife, and premature appearance of the anastomosis stricture were statistically significant influences on the outcome (P <0.05). Considering only the patients (n = 8) with the most favorable predictive factors (interval to stricture formation 12 months or longer, stricture length 1.5 cm or less, and hydronephrosis grade I-II), the success rate was 100%. No complications were observed.nnnCONCLUSIONSnCNI is an effective and minimally invasive treatment for primary UASs, providing durable results compared with other modalities used for endoureterotomy, and should be considered as an initial approach. The selection of patients with the most favorable prognostic factors leads to excellent results. As a secondary procedure, CNI was not successful.

Transurethral electrovaporization vs transurethral resection for symptomatic prostatic obstruction: a meta‐analysis

To compare the effectiveness and safety of transurethral electrovaporization (TUEVP) and transurethral resection of the prostate (TURP) for symptomatic bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH).

History of ureteropelvic junction obstruction repair (pyeloplasty). From Trendelenburg (1886) to the present

ZusammenfassungDie erste plastische Operation zur Korrektur der Harnleiterabgangsstenose (HAS) wurde 1886 von Trendelenburg durchgeführt. Die wichtigen Meilensteine bei der Behandlung der HAS werden historisch diskutiert und alle seit 1886 verfügbaren medizinhistorischen Publikationen werden überprüft. Küster publizierte 5xa0Jahre nach Trendelenburg die erste erfolgreiche „dismembered pyeloplastic“, aber seine Technik neigte zu Strikturen. 1892 führte Fenger das Heineke-Mikulicz-Prinzip ein, welches zur Schwellung und Obstruktion führte. Die Nierenbeckenplikation wurde erstmals von Israel 1896 durchgeführt und durch Kelly 1906 modifiziert.Nach dem Pyloroplastikprinzip von Finney entwarf von Lichtenberg 1921 seine Pyeloplastik, die für die hohe Ureterimplantation geeignet war. Foley modifizierte 1937 die Y-V-Pyeloplastik erfolgreich, die schon Schwyzer 1923 nach dem Pyloroplastikprinzip von Durante eingeführt hatte. Culp u. de Weerd führten 1951 die Spirallappenplastik ein. Scardino u. Prince referierten 1953 über die Verwendung von Vertikallappen. Patel publizierte 1982 die Extralang-Spirallappentechnik. Um die Anastomosenstriktur zu vermeiden, modifizierte 1949 Nesbit die Küster’sche „dismembered Pyeloplastik“ mittels einer elliptischen Anastomose. Gleichzeitig publizierten Anderson u. Hynes ihre Technik.Mit dem Beginn der endourologischen Epoche wurden verschiedene minimal-invasive Verfahren verwendet: Ballondilatation, antegrade oder retrograde Endopyelotomie und laparoskopische Pyeloplastik. Das Konzept der kompletten Inzision des stenosierten Ureterteils gefolgt von prolongiertem Stenting wurde 1903 durch Albarran eingeführt und 1943 durch Davis popularisiert. Zusammenfassend sollten folgende Grundprinzipien zur erfolgreichen Rekonstruktion der HAS eingehalten werden: Weite, durchgängige, wasserdichte und spannungsfreie Anastomose. Die Endopyelotomie erweist sich als eine interessante Alternative zur offenen Operation.AbstractThe first reconstructive procedure for ureteropelvic junction (UPJ) obstruction was performed by Trendelenburg in 1886. The important milestones in the reconstruction of UPJ are discussed and all available historical papers and reports since 1886 are reviewed. Küster published the first successful dismembered pyeloplasty 5xa0years later, but his technique was prone to strictures. In 1892, the application of the Heineke-Mickulicz principle by Fenger resulted in bulking and kinking with obstruction. Plication of the renal pelvis, first introduced by Israel in 1896, was modified by Kelly in 1906.After the principle of the Finney pyloroplasty, von Lichtenberg designed his pyeloplasty in 1921, best suited to cases of high implantation of the ureter. Foley modified flap techniques, first introduced by Schwyzer in 1923 after the application of the Durante pyloroplasty principle, successfully to Y-V pyeloplasty in 1937. Culp and de-Weerd introduced the spiral flap in 1951. Scardino and Prince reported about the vertical flap in 1953. Patel published the extra-long spiral flap technique in 1982. In order to decrease the likelihood of stricture, Nesbit, in 1949, modified Küster’s procedure by utilizing an elliptic anastomosis. In the same year, Anderson and Hynes, published their technique.With the advent of endourology, several minimally invasive procedures were applied: antegrade or retrograde endopyelotomy, balloon dilation, and laparoscopic pyeloplasty. The concept of full-thickness incision of the narrow segment followed by prolonged stenting was first described in 1903 by Albarran and was popularized by Davis in 1943. Several basic principles must be applied in order to ensure successful repair: the resultant anastomosis should be widely patent, performed in a watertight fashion without tension. Endopyelotomy represents an alternative to open surgery.

Antegrade Percutaneous Endoluminal Treatment of Non–Malignant Ureterointestinal Anastomotic Strictures following Urinary Diversion

Objective: We report our experience on antegrade percutaneous incision of ureterointestinal anastomosis strictures after urinary diversion. Materials and Methods: Since 1994, we have evaluated retrospectively 18 patients with 22 ureterointestinal anastomosis strictures (UAS), who were treated with cold–knife incision. After placement of an 8–french nephrostomy tube, a 0.035–inch guide wire bypassed the stricture under guidance of a centrally opened (5–french) ureter catheter. A wire–mounted cold–knife was pulled through the strictured area retrogradely under fluoroscopic control. Routinely, following the incision, an 8–french external stent was left in place for 6–8 weeks. Results: After stent removal as a primary procedure, the ureteroenteric area has remained patent in 14 of 19 (74%) UAS. In 3 cases undergoing a secondary or repeated procedure, treatment failed. The average follow–up was 23.5 (range 12–39) months. Failures were associated with radiogenic injury of the ureter in 5 UAS and unexplained in 2. No complication was observed. Conclusion: Percutaneous endourological management of UAS with the cold–knife incision, when used as a primary treatment, is a safe and effective alternative to open surgical repair and should be considered as an initial approach.

Die Geschichte der operativen Behandlung der Harnleiterabgangsstenose (Pyeloplastik)

ZusammenfassungDie erste plastische Operation zur Korrektur der Harnleiterabgangsstenose (HAS) wurde 1886 von Trendelenburg durchgeführt. Die wichtigen Meilensteine bei der Behandlung der HAS werden historisch diskutiert und alle seit 1886 verfügbaren medizinhistorischen Publikationen werden überprüft. Küster publizierte 5xa0Jahre nach Trendelenburg die erste erfolgreiche „dismembered pyeloplastic“, aber seine Technik neigte zu Strikturen. 1892 führte Fenger das Heineke-Mikulicz-Prinzip ein, welches zur Schwellung und Obstruktion führte. Die Nierenbeckenplikation wurde erstmals von Israel 1896 durchgeführt und durch Kelly 1906 modifiziert.Nach dem Pyloroplastikprinzip von Finney entwarf von Lichtenberg 1921 seine Pyeloplastik, die für die hohe Ureterimplantation geeignet war. Foley modifizierte 1937 die Y-V-Pyeloplastik erfolgreich, die schon Schwyzer 1923 nach dem Pyloroplastikprinzip von Durante eingeführt hatte. Culp u. de Weerd führten 1951 die Spirallappenplastik ein. Scardino u. Prince referierten 1953 über die Verwendung von Vertikallappen. Patel publizierte 1982 die Extralang-Spirallappentechnik. Um die Anastomosenstriktur zu vermeiden, modifizierte 1949 Nesbit die Küster’sche „dismembered Pyeloplastik“ mittels einer elliptischen Anastomose. Gleichzeitig publizierten Anderson u. Hynes ihre Technik.Mit dem Beginn der endourologischen Epoche wurden verschiedene minimal-invasive Verfahren verwendet: Ballondilatation, antegrade oder retrograde Endopyelotomie und laparoskopische Pyeloplastik. Das Konzept der kompletten Inzision des stenosierten Ureterteils gefolgt von prolongiertem Stenting wurde 1903 durch Albarran eingeführt und 1943 durch Davis popularisiert. Zusammenfassend sollten folgende Grundprinzipien zur erfolgreichen Rekonstruktion der HAS eingehalten werden: Weite, durchgängige, wasserdichte und spannungsfreie Anastomose. Die Endopyelotomie erweist sich als eine interessante Alternative zur offenen Operation.AbstractThe first reconstructive procedure for ureteropelvic junction (UPJ) obstruction was performed by Trendelenburg in 1886. The important milestones in the reconstruction of UPJ are discussed and all available historical papers and reports since 1886 are reviewed. Küster published the first successful dismembered pyeloplasty 5xa0years later, but his technique was prone to strictures. In 1892, the application of the Heineke-Mickulicz principle by Fenger resulted in bulking and kinking with obstruction. Plication of the renal pelvis, first introduced by Israel in 1896, was modified by Kelly in 1906.After the principle of the Finney pyloroplasty, von Lichtenberg designed his pyeloplasty in 1921, best suited to cases of high implantation of the ureter. Foley modified flap techniques, first introduced by Schwyzer in 1923 after the application of the Durante pyloroplasty principle, successfully to Y-V pyeloplasty in 1937. Culp and de-Weerd introduced the spiral flap in 1951. Scardino and Prince reported about the vertical flap in 1953. Patel published the extra-long spiral flap technique in 1982. In order to decrease the likelihood of stricture, Nesbit, in 1949, modified Küster’s procedure by utilizing an elliptic anastomosis. In the same year, Anderson and Hynes, published their technique.With the advent of endourology, several minimally invasive procedures were applied: antegrade or retrograde endopyelotomy, balloon dilation, and laparoscopic pyeloplasty. The concept of full-thickness incision of the narrow segment followed by prolonged stenting was first described in 1903 by Albarran and was popularized by Davis in 1943. Several basic principles must be applied in order to ensure successful repair: the resultant anastomosis should be widely patent, performed in a watertight fashion without tension. Endopyelotomy represents an alternative to open surgery.