Wassilios Bentas

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.

Robotic Technology and the Translation of Open Radical Prostatectomy to Laparoscopy: The Early Frankfurt Experience with Robotic Radical Prostatectomy and One Year Follow-up

OBJECTIVE Laparoscopic radical prostatectomy is a complex procedure and has been standardized only during the last years. The remote controlled da Vinci Surgical System has opened up a new era in minimally invasive surgery. We here present our initial experience with the translation of open retropubic radical prostatectomy to laparoscopic technique using da Vinci and a one year follow-up. METHODS After a period of technical development and training on cadavers, 40 consecutive patients eligible for radical prostatectomy were treated. After port placement, the urologist took control of the 3D 30 degrees laparoscope and the two instrument arms at the da Vinci remote console to perform bilateral pelvic lymph node dissection, radical prostatovesiculectomy and urethrovesical anastomosis. RESULTS The procedure was completed laparoscopically in all but two patients. Mean procedure time was 8.3 hours and mean intra-operative blood loss 570 ml. Learning curves associated with the use of the da Vinci Surgical System show that there is a 22-minute decrease in time required to perform the radical prostatectomy and lymphadenectomy for each case (p<0.0001). Patients recovered rapidly after surgery with early oncological and functional results that were similar to those obtained with our standard radical prostatectomy technique. CONCLUSIONS Remote controlled robotic surgical systems are useful to translate open retropubic radical prostatectomy to laparoscopy. This new technology has the potential to equip the urologist with the microsurgical precision needed to preserve the delicate structural integrity of the pelvic floor in order to improve functional results without compromising the oncological outcome.

Robotic surgery in urology: fact or fantasy?

Advanced robotic surgery was first introduced into urology in 2000. The first studies showed the feasibility and safety of the daVinci (Intuitive Surgical Inc., Sunnyvale, CA) telemanipulator assistance in radical prostatectomy, pelvi‐ureteric junction obstruction, and radical cystectomy and neobladder formation. The miniature endowristed tools offer a potential advantage over standard laparoscopy in the accuracy of preparation and suturing. Other features are a three‐dimensional vision system and unimpaired hand‐eye coordination. Complex laparoscopic tasks are learned faster by using the robot, which may also explain the shorter training required for radical prostatectomy than for manual laparoscopy. This new and expensive technology has spread rapidly over the last 4 years. By 2004, ≈ 10% of radical prostatectomies in the USA will be robot‐assisted. Data on the functional and oncological outcomes are accruing but not yet conclusive. There will be a further spread of robotic surgery, routine telesurgery, smaller and more affordable systems, the introduction of virtual reality, all developments which have the potential to urological surgeons to improve.

Laparoscopic Transperitoneal Adrenalectomy Using a Remote-Controlled Robotic Surgical System

BACKGROUND AND PURPOSE Laparoscopic adrenalectomy is considered the standard method for removal of benign adrenal tumors. Although laparoscopic surgery provides clear patient benefit, laparoscopic adrenalectomy using conventional instrumentation is complex. Our objective was to evaluate whether the da Vinci trade mark Surgical System, a comprehensive robotic endoscopic surgical device, could be used effectively to perform laparoscopic adrenalectomy. PATIENTS AND METHODS Through a transperitoneal approach, three right and one left adrenal tumors were removed in four patients using this method. RESULTS There were no complications, and the clinical results were excellent. CONCLUSION We demonstrate the feasibility of performing laparoscopic adrenalectomy exclusively by using robotic telepresent technology from a remote workstation. The da Vinci System enables conventionally trained urologic surgeons to perform complex minimally invasive procedures with ease and precision. Therefore, we are convinced that the system helps the urologist to adapt the whole spectrum of laparoscopic procedure in this field.

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.

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.

Postoperative Voiding Dysfunction in Older Male Renal Transplant Recipients

OBJECTIVE To evaluate the incidence of voiding dysfunction in older male renal transplant recipients. PATIENTS AND METHODS Data for 103 patients aged 60 years or older (mean age, 65.7 years; group 1) who underwent transplantation at our center between January 1999 and August 2007 were compared with data for a group of 139 younger patients (mean age, 50.1 years; group 2) treated within the same time frame. RESULTS Postoperatively, 28 group 1 recipients (27%) and 26 group 2 recipients (19%) experienced voiding dysfunction after removal of the transurethral catheter (P = .12). The most common cause was bladder outlet obstruction due to benign prostatic hyperplasia in 26 patients in group 1 (25%) and 17 patients in group 2 (12%) (P = .009). Bladder neck contracture, urethral stricture, and detrusor underactivity were diagnosed in the other patients. Transurethral resection of the prostate gland was performed in 21 group 1 patients (20%) and 14 group 2 patients (10%) (P = .02) at a mean of 31.1 and 29.5 days, respectively (P = .23) after transplantation. Surgical procedures were performed without complication, and symptoms did not recur postoperatively. CONCLUSIONS Our data reveal a high incidence of voiding dysfunction in older male renal transplant recipients. High residual urine and urinary retention after renal transplantation may induce recurrent urinary tract infections, cause relevant complications, and seriously affect graft function. Recognizing the substantial effects of postoperative voiding dysfunction will enable optimum management of older kidney transplant recipients.

Angiogenesis inhibition by angiostatin, endostatin and TNP-470 prevents cyclophosphamide induced cystitis.

Angiogenesis, the induction of vessel growth is involved in numerous physiological and pathological processes. While the anti-tumor effect of angiogenesis inhibitors has been extensively investigated in malignant tumors, there is very little information on the effect of angiogenesis inhibitors on inflammation induced angiogenesis. In this report, we utilized a murine model of acute chemically induced cystitis to investigate the ability of three different angiogenesis inhibitors, angiostatin, endostatin and TNP-470, to inhibit the angiogenesis stimulated by this injury. We demonstrate herein, that prophylactic application of the angiogenesis inhibitors led to a significant reduction of each of the inflammatory parameters that were measured. We conclude that anti-angiogenic therapy with angiostatin, endostatin and TNP-470 inhibits inflammation associated angiogenesis induced in this model. We also propose that anti-angiogenic agents may serve as a valuable addition to a standard cyclophosphamid chemotherapy regimen to help reduce the chemotherapy-related side effects while potentially adding an anti-tumor effect.

Serum Angiogenic Activity: Diagnostic Relevance in Renal Cell Carcinoma

OBJECTIVE Angiogenesis is essential for tumor growth and progression. However, reported data on angiogenic parameters in patients with renal cell carcinoma are contradictory. The objective of this study was to use serum to compare the systemic angiogenic activity in patients with renal cell carcinoma and to determine if pathologic stage and grade correlated to this angiogenesis parameter. METHODS Serum of 28 patients with a newly diagnosed renal cell carcinoma, 28 healthy volunteers and 9 patients with bladder carcinoma were used for this study. All sera were tested in a 72-hour endothelial cell proliferation assay. In addition the serum concentrations of the angiogenesis stimulators basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) were determined using standard ELISA assays. RESULTS The serum of renal cell carcinoma patients showed a median stimulation of human umbilical vein endothelial cells (HUVEC) of 89.79% (range 58.47-147.95%) and serum of healthy volunteers showed a median stimulation of 95.35% (range 74.64-141.77%) (p > 0.05). In contrast serum of patients with bladder carcinoma showed a median stimulation of 140.16% (range 64.82-200.16%) (p = 0.024). No correlations of the serum angiogenic activity and tumor stage or grade have been found in renal cell carcinoma patients. Furthermore, no correlations for serum bFGF and VEGF concentrations have been found. CONCLUSIONS Serum angiogenic activity of patients with renal cell carcinoma did not differ significantly from healthy controls, while serum of patients with bladder carcinoma showed a significant increase in endothelial cell stimulation. Furthermore, bFGF and VEGF serum concentrations did not correlate to serum angiogenic activity in patients with renal cell carcinoma. Therefore, the determination of systemic angiogenic parameters, in case of renal cell carcinoma, might not lead to adequate data concerning prognosis or therapeutic effects.

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.