Are there limits of robotic partial nephrectomy? TRIFECTA outcomes of open and robotic partial nephrectomy for completely endophytic renal tumors.

BACKGROUND: To compare the outcomes of robot-assisted (RAPN) and open partial nephrectomy (OPN) for completely endophytic renal tumors. METHODS: Consecutive patients undergoing OPN or RAPN for entirely endophytic tumors in four high-volume centers between 2008 and 2016 were identified. Endophytic masses were identified based on sectional imaging. Patient characteristics and surgical outcome were compared using Mann-Whitney-U-test and chi-squared-tests. Uni- and multivariate analyses were performed to identify predictors of TRIFECTA achievement and excisional volume loss. RESULTS: Out of 1128 patients, 10.9% (64) of RAPN and 13.9% (76) of OPN underwent surgery for entirely endophytic tumors. Operative time was longer for RAPN (169 vs 140 min, P = 0.03) while ischemia time was shorter (13 vs 18 min, P = 0.001). Complication rates were comparable (21% OPN vs 22% RAPN, P = 0.91) and TRIFECTA achievement was not different between the groups (68% OPN vs 75% RAPN, P = 0.39). In multivariate analyses type of surgery was not associated with TRIFECTA achievement or excisional volume loss. Here, only tumor complexity (OR 0.48, P = 0.001) and size (OR 1.01, P = 0.002) were independent predictors. CONCLUSION: For entirely endophytic tumors, both RAPN and OPN offer good TRIFECTA achievement. This encourages the use of NSS even for these highly complex tumors using the surgeon's preferred approach.

Adreno-muscarinic synergy in the male human urinary outflow tract.

AIM: To examine putative interaction between adrenergic and muscarinic contractile activation in the human urinary outflow tract. METHODS: Tissue from the trigone and prostatic urethra was obtained from 12 cystectomy and 16 prostatectomy specimen. Contractions were elicited by exposure to exogenous agonists before and after inhibition of Rho kinase and protein kinase c (PKC). Immunofluorescence and Western-blot studies were performed using antibodies to muscarinic M3-receptors (M3-R) and alpha1A-adrenoreceptors (alpha1A-AR). The study is registered with ClinicalTrials.gov, number NCT01227447. RESULTS: There was strong co-localization of M3-R and alpha1A-AR on trigonal and urethral myocytes. Western blot analysis revealed a significantly higher expression of alpha1A-AR in the superficial than in the deep trigone. Phenylephrine (PE, 1 µm) augmented contractions induced by carbachol (CA, 3 µm) to more than threefold control in the male superficial trigone, and to about sevenfold control in the proximal urethra. No such potentiation could be detected in female bladder outlet. Both PKC inhibitor GF 109203X and Rho kinase inhibitor Y-27632 reduced responses to 1 µM PE as well as to 3 µM CA significantly. However, the synergistic effect of the combined intervention remained proportionally unaffected. CONCLUSIONS: Muscarinic and adrenergic receptor activation exerts a strong synergistic effect in the male human bladder trigone and proximal urethra.

Tumor complexity and the impact on MIC and trifecta in robot-assisted partial nephrectomy: a multi-center study of over 500 cases.

PURPOSE: To demonstrate the surgical feasibility of robot-assisted partial nephrectomy for complex renal masses with comparison of low/intermediate risk versus high-risk tumors according to the PADUA score. METHODS: Since 2008, 538 robot-assisted partial nephrectomies were performed at three German robotic centers. Both the MIC (margin, ischemia, complications) criteria and trifecta were applied. RESULTS: 60.1% of the tumors were of low and intermediate complexity (PADUA score 6-9, n = 326, group A), while 39.9% were highly complex (n = 212, score ≥ 10, B). Median clinical tumor size was 28 in A versus 37 mm in B (p < 0.001). There was no significant difference in terms of operative time (160 vs. 163 min, p = 0.20); ischemia time was slightly longer for B (11 vs. 12 min, p < 0.001). There were no significant differences for intra- (3.4%, A, vs. 6.6%, B, p = 0.10) or postoperative (21.5%, A, vs. 25.5%, B, p = 0.30) complication rates. There was a median eGFR decrease of - 9.4 (A) versus - 15.1 (B) ml/min (p < 0.001) on discharge. Histopathology revealed an R1 margin rate of 3.4% for the low/intermediate versus 6.1% for the high complexity group (p = 0.14). MIC criteria were fulfilled in 81.9% (A) versus 75.5% (B, p = 0.11) and trifecta criteria in 74.2% (A) versus 68.93% (B, p = 0.26). CONCLUSIONS: Complication rates, histopathology results as well as quality criteria as indicated by MIC and trifecta were similar for high and low complexity groups. Therefore, robot-assisted partial nephrectomy is a safe and feasible option also in highly complex tumors.

Outcome of Robotic Radical Prostatectomy in Men Over 74.

INTRODUCTION: We set out to evaluate outcomes in patients over 74 after robotic radical prostatectomy. MATERIALS AND METHODS: Six hundred forty-seven patients over 74 (≥75) were analyzed for preoperative factors (body mass index [BMI], American Society of Anestesiologists classification [ASA], prostate-specific antigen [PSA], International prostate symptome score [IPSS], International index of erectile function [IIEF]), operative and perioperative characteristics (technique, erythrocyte conc., complications), and histopathological results. After 12 months, following items were assessed: PSA, frequency of urine loss, number of pads used (including safety), incontinence at night, and potency as quantified by IIEF-5. RESULTS: Mean age in the group <75 was 64.8 years (range 46-74 years) and in the group ≥75 76.9 years (75-88). No statistically significant differences could be detected in terms of BMI, ASA score, or preoperative PSA, respectively. IPSS and IIEF were significantly worse in the group ≥75. Major complications (>Clavien-Dindo III) were found in 1.6% vs. 1.3% (≥75) of cases. Minor complications were encountered in 22.8% vs. 26.3% (≥75). There was a remarkably high percentage of locally advanced disease (73.3% vs. 71.0%) in both groups. Patients ≥75 showed a tendency toward more aggressive cancer and more frequent nodal involvement; we found a higher percentage of R1-resections (19.5% vs. 30.4%, p < 0.05) and PSA relapse after 1 year (12.3% vs. 22.8%, p < 0.05). Twelve months pad-free continence rate (69.9% vs. 63.2%) showed no statistically significant difference between both groups as did the preservation rate of erectile function. CONCLUSION: We could show that robotic prostatectomy can be carried out safely with good functional and histopathological results in patients ≥75. It is therefore questionable if elderly patients can be precluded from curative radical treatment solely because of their age.

Minimally Invasive Repair of a Prostatorectal Fistula with an Over-the-Scope Rectal Clip.

Background: Fistulae between the prostatic urethra and the rectum are rare. They may result from prostatic or rectal surgery. Predisposing factors are previous radiation or immunosuppression. The repair of such fistulae usually involves major surgery. Recently, clips that can be deployed over an endoscope have been developed to close gastrointestinal fistulae or access points for natural orifice surgery. We report the first case of effective treatment of a prostatorectal fistula with a rectal "over-the-scope" clip. Case Presentation: A 64-year-old man under chronic immunosuppression presented with an iatrogenic fistula between the prostatic urethra and the rectum after transurethral resection of the prostate. A transverse colostomy was placed but the fistula failed to heal conservatively. The fistula was effectively closed with an endorectal clip. Six weeks after the procedure, spontaneous micturition was started. Two weeks further, the colostomy was reversed. At 32 months of follow-up, the remains closed, micturition is unimpaired. Conclusion: In select cases of prostatorectal fistula, an endorectal clip may be effectively used for closure.

"Finding the needle in a haystack": oncologic evaluation of patients treated for LUTS with holmium laser enucleation of the prostate (HoLEP) versus transurethral resection of the prostate (TURP).

PURPOSE: To evaluate oncologic parameters of men with bothersome LUTS undergoing surgical treatment with HoLEP or TURP. METHODS: Five hundred and eighteen patients undergoing HoLEP (n = 289) or TURP (n = 229) were retrospectively analyzed for total PSA, prostate volume, PSA density, history of prostate biopsy, resected prostate weight, and histopathological features. Univariate and multivariate logistic regression models were used to identify independent predictors of incidental PCa (iPCa). RESULTS: Men undergoing HoLEP had a significantly higher total PSA (median 5.5 vs. 2.3 ng/mL) and prostate volume (median 80 vs. 41 cc), and displayed a greater reduction of prostate volume after surgery compared to TURP patients (median 71 vs. 50%; all p < 0.001). With a prevalence of incidental PCa (iPCa) of 15 and 17% for HoLEP and TURP, respectively, the choice of procedure had no influence on the detection of iPCa (p = 0.593). However, a higher rate of false-negative preoperative prostate biopsies was noted among iPCa patients in the HoLEP arm (40 vs. 8%, p = 0.007). In multivariate logistic regression, we identified patient age (OR 1.04; 95% CI 1.01-1.07, p = 0.013) and PSA density (OR 2.13; 95% CI 1.09-4.18, p = 0.028) as independent predictors for the detection of iPCa. CONCLUSIONS: Despite differences in oncologic parameters, the choice of technique had no influence on the detection of iPCa. Increased patient age and higher PSA density were associated with iPCa. A higher rate of false-negative preoperative prostate biopsies was noted in HoLEP patients. Therefore, diagnostic assessment of LUTS patients requires a more adapted approach to exclude malignancy, especially in those with larger prostates.

Is One Early Renographic Follow-Up Adequate to Measure the Success of Robotic Pyeloplasty?

PURPOSE: Diuretic renography (DRG) is commonly used to diagnose ureteropelvic junction obstruction (UPJO) and to evaluate the success of surgical repair (pyeloplasty). Duration, frequency, and interpretation of renographic follow-ups are still under dispute. METHODS: We retrospectively reviewed 94 consecutive patients diagnosed with UPJO who underwent a minimally invasive, robotically assisted laparoscopic pyeloplasty at our institution between January 2009 and September 2015. DRG was carried out preoperatively and again routinely 4 to 6 weeks postoperatively the day after stent removal (early DRG). Patients were scheduled for repeat (late) DRG and follow-up examinations, including clinical status and ultrasonography. RESULTS: Nineteen patients with missing preoperative DRG were excluded from the study; the remaining 75 patients were eligible for statistical evaluation. At follow-up, 98.7% reported no or only very mild and rare symptoms. On early DRG, 52.5% had T1/2 ≤ 10 min (unobstructed), 39.3% had T1/2 between 10 and 20 minutes (equivocal), and 8.2% had T1/2 ≤ 20 minutes (obstructed). At late follow-up, the DRG results had improved to 80.8% unobstructed with 19.2% remaining equivocal, and no patients were obstructed; thus, the overall success rate was 80.8%. There was only one patient who worsened from unobstructed to equivocal from early to late DRG assessment. CONCLUSION: In case of complete symptom resolution, a nonobstructive diuretic half-time of ≤10 minutes on early DRG following stent removal suggests that further routine renographic follow-up is unnecessary. Patients with an equivocal early DRG (T1/2 between 10 and 20 minutes) require further scintigraphic follow-up, as they have a 42.1% chance of staying equivocal.

Poor standard mp-MRI and routine biopsy fail to precisely predict intraprostatic tumor localization.

PURPOSE: To evaluate the localization accuracy of routinely performed preoperative multiparametric MRI (mp-MRI), not being assessed according to PI-RADS criteria. METHODS: One hundred and six patients underwent radical retropubic prostatectomy (January 2011-June 2012) with preoperative MRI. Intraprostatic tumor localization suggested by mp-MRI was correlated to both biopsy and histopathology results. RESULTS: Sensitivity and specificity were as low as 25-62 and 60-94 %, respectively. Neither higher field force nor the use of an endorectal coil could enhance accuracy. There was no statistically significant concordance in any sextant. The mean number of correctly identified sextants was between 3.11 and 4.00 and, thus, insignificantly above the value of 3 that one would obtain by tossing the coin. For transrectal biopsies, sensitivity and specificity of tumor localization were 52-63 and 46-80 %, respectively. CONCLUSIONS: Neither routinely performed "non-PI-RADS" MRI nor transrectal biopsy can accurately localize prostate cancer. Focal therapy concepts rely on a precise intraprostatic tumor detection and therefore inevitably require PI-RADS assessment by radiologists with genitourinary specialization. Regarding patient discomfort and costs, "non-PI-RADS" MRIs of the prostate are not justified.

[PSA screening]. / PSA zur Früherkennung des Prostatakarzinoms.

Screening for prostate cancer should help to detect malignancy at an early and potentially treatable stage. Serum psa has been used as a test for prostate cancer for over 20 years, but its practise is still very controversial worldwide. Studies can demostrate good aspects for screening with psa: the overall mortality and especially the metastases at stage of primary diagnosis can be reduced. A relevant factor is measuring the serum psa in younger men aged 40-50 for a baseline to evaluate the individual risk of prostate cancer. Furthermore, it is important not to exclude patients because of their age of measuring the psa. The individual life expectancy should help to decide about its usefulness. This aspect is especially important in the face of an increasing life expectancy and fitness level at old age. Further studies are needed to publish a recommendation for psa-screening. In Germany, the PROBASE is a current study to research this topic.

A comparative assessment of prostate positioning guided by three-dimensional ultrasound and cone beam CT.

BACKGROUND: The accuracy of the Elekta Clarity™ three-dimensional ultrasound system (3DUS) was assessed for prostate positioning and compared to seed- and bone-based positioning in kilo-voltage cone-beam computed tomography (CBCT) during a definitive radiotherapy. METHODS: The prostate positioning of 6 patients, with fiducial markers implanted into the prostate, was controlled by 3DUS and CBCT. In total, 78 ultrasound scans were performed trans-abdominally and compared to bone-matches and seed-matches in CBCT scans. Setup errors detected by the different modalities were compared. Systematic and random errors were analysed, and optimal setup margins were calculated. RESULTS: The discrepancy between 3DUS and seed-match in CBCT was -0.2 ± 2.7 mm laterally, -1.9 ± 2.3 mm longitudinally and 0.0 ± 3.0 mm vertically and significant only in longitudinal direction. Using seed-match as reference, systematic errors of 3DUS were 1.3 mm laterally, 0.8 mm longitudinally and 1.4 mm vertically, and random errors were 2.5 mm laterally, 2.3 mm longitudinally, and 2.7 mm vertically. No significant difference could be detected for 3DUS in comparison to bone-match in CBCT. CONCLUSIONS: 3DUS is feasible for image guidance for patients with prostate cancer and appears comparable to CBCT based image guidance in the retrospective study. While 3DUS offers some distinct advantages such as no need of invasive fiducial implantation and avoidance of extra radiation, its disadvantages include the operator dependence of the technique and dependence on sufficient bladder filling. Further study of 3DUS for image guidance in a large patient cohort is warranted.

Preoperative mp-MRI of the prostate provides little information about staging of prostate carcinoma in daily clinical practice.

PURPOSE: To evaluate the staging accuracy of preoperative multiparametric MRI (mp-MRI), its influence on the technique of radical retropubic prostatectomy (RRP), and its value for daily clinical practice. METHODS: A total of 106 patients underwent RRP (January 2011-June 2012) and had preoperative MRI staging data available for review. Staging results acquired by mp-MRI were correlated to both biopsy and histopathology results. Surgical reports were reviewed for intraoperative aspect of tumor extension, technique of RRP (nerve sparing or extended), and extent of lymphadenectomy. RESULTS: The accuracy of diagnosing extracapsular extension (ECE) was 72.2 %, with an overall sensitivity and specificity of 30.0 and 93.3 %, respectively. The negative predictive value was 72.7 %. The sensitivity and specificity to diagnose positive seminal vesical invasion (SVI) were 63.6 and 92.9 %, respectively. Neither higher field force nor the use of an endorectal coil could enhance the accuracy of mp-MRI. In case of awareness of an existing MRI, there was a significantly higher percentage of nerve protection (left: 93 %; right: 89 % vs. left 75 %; right: 75 %). The higher percentage of nerve sparing surgery did not result in a higher level of positive resection margins. CONCLUSIONS: In routine clinical practice, mp-MRI at non-academic centers has very limited clinical value in predicting ECE and SVI. Our data support the current recommendations against the widespread preoperative use of mp-MRI because it is not adding reliable predictive information on the extent of prostate cancer.

Single fraction radiosurgery for the treatment of renal tumors.

PURPOSE: High dose local stereotactic radiosurgery was performed in select patients to improve local tumor control and overall survival. We report on patients with renal tumors treated with single fraction robotic stereotactic radiosurgery. MATERIALS AND METHODS: A total of 40 patients with a median age of 64 years who had an indication for nephrectomy and subsequent hemodialysis were entered in a prospective case-control study of single fraction stereotactic radiosurgery. Of the patients 11 had transitional cell cancer and 29 had renal cell cancer. Tumor response, renal function, survival and adverse events were estimated every 3 months. Followup was at least 6 months. RESULTS: A total of 45 renal tumors were treated. Median followup was 28.1 months (range 6.0 to 78.3). The local tumor control rate 9 months after stereotactic radiosurgery was 98% (95% CI 89-99). There was a measurable size reduction in 38 lesions, including complete remission in 19. Renal function remained stable. Using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation median creatinine clearance was 76.8 (range 25.3 to 126.3) and 70.3 ml/minute/1.73 m(2) (range 18.6 to 127.3) at baseline and followup, respectively (p = 0.89). Grade I erythrodermia developed in 1 patient, 3 reported grade I fatigue and 2 reported grade I nausea. Nephrectomy was avoided in all cases. CONCLUSIONS: Single fraction stereotactic radiosurgery as an outpatient procedure is a treatment modality with short-term safety and efficacy. It avoids treatment related loss of renal function and hemodialysis in select patients with transitional or renal cell cancer. At short followup oncologic results were similar to those of other ablative techniques for renal tumors. To date functional results have been excellent. Further studies are needed to determine the long-term results and limits of stereotactic radiosurgery in this setting.

Urethral stricture: etiology, investigation and treatments.

BACKGROUND: Urethral stricture is a narrowing of the urethra due to scar tissue, which leads to obstructive voiding dysfunction with potentially serious consequences for the entire urinary tract. Its prevalence among men in industrial countries is estimated at 0.9%. It produces obstructive and irritative urinary symptoms and can ultimately impair renal function. Urethral strictures can be caused by diagnostic or therapeutic urological procedures. These procedures are being performed ever more commonly, because the population is aging; thus, urethral strictures will probably become more common as well. METHODS: We selectively reviewed pertinent original articles and meta-analyses (1995-2012) on the causes, diagnostic evaluation, and treatment of urethral strictures, which were retrieved by a search in the PubMed database. RESULTS: Most of the relevant publications are reports of retrospective studies from single centers. Only a few prospective randomized trials and structured reviews are available. The overall level of the scientific evidence is low. 45% of urethral strictures are iatrogenic, 30% idiopathic, and 20% due to bacterial urethritis. Strictures are diagnosed with a flow test and a retrograde urethrogram. Short bulbar strictures can be treated endoscopically. For recurrent and complex strictures, only open urethral surgery can reliably and permanently remove the infravesical obstruction. CONCLUSION: Urethral strictures must be recognized and treated so that their most serious long-term complication, impaired renal function, can be prevented. The clinical utility of urethrotomy is limited by a high recurrence rate.

Impact of the 'repositioning test' on postoperative outcome of retroluminar transobturator male sling implantation.

OBJECTIVE: To evaluate prospectively the value of the 'repositioning test' (RT) in preoperative patient selection for the efficacy of male stress urinary incontinence (SUI) treatment using a retroluminar transobturator male sling (AdVance sling). PATIENTS AND METHODS: 65 consecutive patients with SUI after radical prostatectomy were included in this single-center prospective study. Preoperatively, patients were classified into those with 'positive' and 'negative' RT. Postoperative results were analyzed and the association between the result of the RT and postoperative outcome was evaluated. RESULTS: 53 patients (81.5%) showed preoperatively a positive RT and 12 patients (18.5%) a negative RT. After a follow-up of 12 months, patients with positive RT showed a cure rate (0 pads/day) of 83% and patients with a negative RT showed only a cure rate of 25%. A positive RT significantly correlated with cure in outcome (p < 0.001). CONCLUSIONS: Patients with positive RT have a significantly better chance for successful AdVance sling implantation. The RT is minimally invasive, easy to learn and easy to perform. Therefore, the RT is a very useful tool for preoperative patient selection.

Contraction of the anterior prostate is required for the initiation of micturition.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: In a recent rtMRI study, we were able to show that, during initiation of voiding, there was both funnelling of the bladder neck and simultaneous contraction of the ventral prostate. We presumed that the vertical contraction of the ventral prostate contributes to the initiation of successful micturition. The question remained as to whether this shortening of the ventral prostate is predominantly caused by contractile elements in the organ itself, or by surrounding contractile elements of the pelvic floor. In our study we provide insight in to anatomical changes, and biometric and functional analysis of the prostate during micturition. A sagittal contraction of the ventral prostate and the longitudinal smooth muscle elements at the onset of voiding, which can be observed on MRI, is likely to shorten and open up the prostatic urethra. OBJECTIVE: To investigate if in vitro contractile strength of the prostate and the prostatic urethra might correlate with the shortening of the ventral prostate seen on real-time magnetic resonance imaging (rtMRI). Micturition is a complex process that includes anatomical and neurological interactions for successful voiding. Recently we described on rtMRI that vertical contraction of the ventral prostate precedes initiation of male micturition and may contribute to the funnelling of the bladder neck. PATIENTS AND METHODS: In all, 10 patients undergoing radical prostatectomy (RP) were enrolled. Approval was obtained from all patients and by the local Ethics Committee. Preoperative rtMRI during voiding was performed as described before in eight patients undergoing RP, measuring the difference of the cranio-caudal distance of the ventral prostate (VP). To roughly estimate the amount of force required to deform the prostate in a vertical direction as seen on rtMRI, we uniaxially compressed the organ immediately after surgery by the same distance, assuming incompressibility and isotropy of prostatic tissue. A muscle strip (3 × 3 mm) from the ventral prostate, dorsal prostate and prostatic urethra was obtained after pathological evaluation. Contraction was elicited by electrical-field stimulation (EFS: 0.1 ms pulses at 2, 4, 8, 16, 32 and 64 Hz for 4 s). RESULTS: There was a mean cranio-caudal contraction of the ventral prostate by 7.6 mm at the onset of micturition on rtMRI (P = 0.002). The mean (sd) contractile force of strips elicited by EFS at 32 Hz was 1472.44 (706.88) mN for the ventral prostate, 1044.24 (894.66) mN for the dorsal prostate, and 639.10 (785.06) mN for the prostatic urethra (P = 0.02). Extrapolating these values to the whole organ diameter, we calculated comparable force as observed in compression experiments. CONCLUSIONS: Our functional and biometric in vitro analyses of prostate tissue showed sufficient contractile strength of the ventral prostate to induce a shortening of the organ as seen on rtMRI. There was significant higher contractile strength in the ventral prostate than in the dorsal prostate or the proximal urethra. The consistency of in vivo and in vitro results underlines the significance of the ventral prostate for the initiation of normal micturition.

Microbial colonization and ureteral stent-associated storage lower urinary tract symptoms: the forgotten piece of the puzzle?

PURPOSE: Ureteral stents are frequently associated with side effects. Most patients suffer from storage lower urinary tract symptoms (LUTS). Storage LUTS are commonly attributed to the irritation of the trigone, smooth muscle spasm or a combination of factors. The relationship between microbial ureteral stent colonization (MUSC) and de novo or worsening storage LUTS has not been investigated yet. METHODS: Five hundred ninety-one polyurethane ureteral stents from 275 male and 153 female patients were prospectively evaluated. The removed stents were sonicated to dislodge adherent microorganisms. Urine flow cytometry was performed to detect pyuria. A standardized urinary symptom questionnaire was given to all patients. RESULTS: Thirty-five per cent of male and 28% of female cases showed de novo or worsened storage LUTS. MUSC was more common in patients with storage LUTS compared to patients without storage LUTS (men: 26 vs. 13%, respectively, P < 0.05; women: 63 vs. 48%, respectively, P = 0.13). Pyuria was significantly more common in patients with storage LUTS compared to patients without storage LUTS (men: 55 vs. 40%, respectively, P < 0.05; women: 70 vs. 45%, respectively, P < 0.05). No significant correlation was observed between the detected genera of microorganisms and storage LUTS. CONCLUSIONS: Our data show a significant association between MUSC- and stent-related de novo experienced or worsened storage LUTS in men. The incidence of MUSC is most common in both female and male patients with storage LUTS and accompanying pyuria. In these patients, a combination of antibiotics and anti-inflammatory drugs may be regarded as treatment option.