Ideal timing of indwelling catheter removal after robot-assisted radical prostatectomy with a running barbed suture technique: a prospective analysis of 425 consecutive patients.

OBJECTIVE: To compare prospectively early outcome and complications of catheter removal after robot-assisted radical prostatectomy (RARP) on the 4th or 7th day with a standardized running barbed suture technique. INTRODUCTION: The time point of removing the indwelling catheter after RARP mainly depends on institute's/surgeon's preferences. Removal should be late enough to avoid urinary leakage and complications such as acute urinary retention (AUR) but early enough to avoid unnecessary catheter indwelling. MATERIALS AND METHODS: A consecutive single-institutional series of patients underwent RARP between July 2015 and August 2017 and were entered in a prospectively maintained data base. Between July 2015 and December 2016 a cystogram was performed on 7th postoperative day (group A), thereafter the cystogram was performed on 4th postoperative day (group B). Incidence of acute urinary retention (AUR), urinary tract infections (UTI) and adverse events between the two cohorts was compared. RESULTS: 425 patients were analyzed (group A: n = 231; group B: n = 194). Both cohorts were comparable regarding demographic and oncological parameters. Watertight anastomosis was present in 84.8% in group A and in 82.5% in group B, respectively. AUR within 4 weeks after RARP occurred in 2.2% (n = 3) in A and 9.4% (n = 15) in B (p = 0.001). AUR within 72 h after catheter removal occurred in group A: 1% (n = 2) and in group B: 6.3% (n = 10) (p = 0.005). Symptomatic urinary tract infections occurred in 8.2% (n = 16) in group A and in 6.9% (n = 11) in group B. There were no differences in the rate of secondary anastomosis dehiscence. Age, BMI, prostate size, surgeon, or intraoperative bladder neck reconstruction were not correlated to the occurrence of AUR or UTI. CONCLUSIONS: The removal of indwelling catheter on day 4 after a RARP with a running barbed suture shows similar anastomosis leakage rates as on the 7th postoperative day. However, AUR rates are higher for early removal. Patients scheduled for early removal should be carefully informed about the increased risk for AUR. Catheter indwelling time does not represent a risk factor for UTI.

Outcome of sonography-based minimally invasive surgery for deep infiltrating endometriosis of the ureter and urinary bladder - a retrospective cohort study.

INTRODUCTION: The aim of this study was to evaluate the accuracy of transvaginal sonography for preoperative detection of bladder endometriosis and surgical outcomes regarding fertility and pain symptoms of women with urinary tract endometriosis. MATERIAL AND METHODS: Retrospective cohort study of consecutive patients with urinary tract endometriosis undergoing laparoscopic partial cystectomy and/or ureterolysis/decompression, ureteric resection and end-to-end anastomosis or ureteroneocystostomy for ureteral stenosis and hydronephrosis. RESULTS: Of 207 patients with deep infiltrating endometriosis, 50 exhibited urinary tract endometriosis, comprising 30 patients with bladder endometriosis and 23 women with solitary or additional hydronephrosis. Sensitivity, specificity, positive and negative predictive value, positive/negative likelihood ratios and test accuracy for transvaginal sonography detecting bladder endometriosis were 93%, 99%, 97%, 99%, 155.5, 0.07 and 98.6% respectively. All women with bladder endometriosis underwent partial cystectomy. In cases of hydronephrosis, 14 conservative ureterolysis/decompressions, six ureteral resection anastomoses and three ureteroneocystostomies were performed. Duration of surgery was 205 min (range 89-365 min), average blood loss was 1.6 g/dL (range 0.3-4.6 g/dL) and hospital stay on average 8 days (range 2-16 days). The conversion rate was 4%. We observed five grade III complications. After a median follow up of 23 months, there was a decrease in dysmenorrhea (7.6-1.6; p < 0.001), dyspareunia (3.0-0.9, p < 0.001) and dysuria (3.3-0.2; p < 0.003), and an increase in quality of life (3.3-8.1; p < 0.001). The overall clinical pregnancy rate was 46% and life birth rate 18%. CONCLUSIONS: Laparoscopic surgery for urinary tract endometriosis is effective for treatment of hydronephrosis, reduction of pain symptoms and may improve fertility. Transvaginal sonography is highly accurate for presurgical detection of bladder involvement.

Neoadjuvant Chemotherapy with Gemcitabine plus Cisplatin in Patients with Locally Advanced Bladder Cancer.

BACKGROUND: Neoadjuvant chemotherapy with methotrexate-vinblastine-doxorubicin-cisplatin (MVAC) is the standard of care for muscle-invasive urothelial bladder cancer. Gemcitabine plus cisplatin (GC) shows similar efficacy with less toxicity in the metastatic setting and has therefore often been used interchangeably with MVAC. We report on the efficacy and safety of neoadjuvant GC in patients with locally advanced urothelial cancer. MATERIALS AND METHODS: We prospectively evaluated 87 patients in 2 centers. Their median age was 68 years. Treatment consisted of 3× GC prior to radical cystectomy. The primary endpoint was pathologic response. The secondary endpoints were safety, progression-free survival (PFS), and overall survival (OS). RESULTS: In all, 83 patients finished chemotherapy; 80 patients were evaluable for the primary endpoint. Pathologic complete response (pCR) was achieved in 22.5% and near pCR was seen in 33.7% of the patients. The 1-year PFS rate was 79.5% among those patients achieving ≤pT2 versus 100% among those patients achieving pCR or near pCR (p = 0.041). Five-year OS was 61.8% (95% CI 67.6 to NA). GC was well tolerated. Grade 3/4 toxicities occurred in 38% of the patients. There was no grade 3/4 renal toxicity, febrile neutropenia, or death. CONCLUSION: Neoadjuvant GC is a well-tolerated regimen. Although the pathologic response is lower than that reported with MVAC, our data support GC as a feasible option in the absence of a prospective randomized comparison, particularly for older patients, since its toxicity is lower than that of MVAC.

[The Clavien-Dindo classification of complications used for radical prostatectomy]. / Die Komplikationsklassifikation nach Clavien-Dindo am Beispiel der radikalen Prostatektomie.

The objective of the present study was to evaluate perioperative complications between retropubic, endoscopic and robot-assisted radical prostatectomy on basis of a prospective maintained database using the Clavien-Dindo classification of complications. According to our results, implementation of the radical robot-assisted laparoscopic prostatectomy shows a trend to a decrease of minor complications compared to retropubic and endoscopic radical prostatectomy. Major complications are comparable between all three procedures.

A randomized, double-blind, placebo-controlled trial of testosterone gel on body composition and health-related quality-of-life in men with hypogonadal to low-normal levels of serum testosterone and symptoms of androgen deficiency over 6 months with 12 months open-label follow-up.

INTRODUCTION: The clinical significance of low to low-normal testosterone (T) levels in men remains debated. AIM: To analyze the effects of raising serum T on lean body mass (LBM), fat mass (FM), total body mass, and health-related quality-of-life (HRQoL). METHODS: Randomized, double-blind, placebo-controlled study. Men, aged 50-80 years, with serum total T<15 nmol/L and bioavailable T < 6.68 nmol/L, and a Aging Males' Symptoms (AMS) total score >36, received 6 months treatment with transdermal 1% T gel (5-7.5 mg/day; n =183) or placebo gel (n =179), followed by 12 months open-label with T in all. RESULTS: After 6 months, LBM increased in T- treated patients by 1.28 ± 0.15 kg (mean ± SE) and FM decreased by 1.16 ± 0.16 kg, with minor changes with placebo (LBM +0.02 ± 0.10 kg and FM -0.14 ± 0.12 kg; all p < 0.001, T group vs. placebo). Changes were largely similar across subgroups of age, baseline total testosterone, and baseline BMI. Total HRQoL improved compared with placebo (p < 0.05, T group vs. placebo). CONCLUSIONS: Six months 1% T gel improved body composition and HRQoL in symptomatic men with low to low-normal T, with further improvements over the following 12 months.

[Neoadjuvant therapy before radical prostatectomy - indications and protocols]. / Neoadjuvante Therapie vor radikaler Prostatektomie - Indikationen und Protokolle.

As neoadjuvant chemotherapy is established for a variety of nonorgan confined malignancies, neoadjuvant hormone ablation for hormone sensitive prostate cancer has demonstrated encouraging results. Neoadjuvant therapy not only provides possible early systemic treatment for subclinical distant disease, but also aims to improve local disease control and to increase the number of patients eligible for definitive local therapy via downstaging. However, only limited, heterogenous studies are available. Therefore, prospective high quality studies are urgently needed to assess the future role of neoadjuvant hormone ablation.

Sentinel lymphadenectomy compared to extended lymphadenectomy in men with prostate cancer undergoing prostatectomy.

BACKGROUND: To evaluate the reliability of sentinel lymphadenectomy compared to extended lymphadenectomy in men undergoing radical prostatectomy (RP). PATIENTS AND METHODS: A consecutive cohort of men with intermediate- to high-risk prostate cancer underwent RP with sentinel LA with intraoperative frozen section. In addition, extended LA was carried out in all cases. The endpoint was lymph node-positivity. RESULTS: In total, 54 men with a mean age of 65.3 (50.9-75.6) years were analyzed. The mean preoperative prostate-specific antigen was 10.6 (2.8-66.5) ng/ml, mean number of disease-positive cores was 5.8 (1-13), digital rectal examination was positive in 29 men (53.7%). In 12 men (22.2%), a positive lymph node was found (pN1). sLA was positive in 11 cases. One patient had a positive lymph node in eLA not found with sLA. The positive predictive value of frozen section was 50%; the respective figure for sLA compared to eLA was 91.6%. CONCLUSION: In this cohort, revealing a high prevalence of disease-positive lymph nodes, sLA was a reliable technique with a low rate of false negativity.

[First experience with the laparoscopic radical cystectomy]. / Erste Erfahrungen mit der laparoskopischen radikalen Zystektomie.

In muscle-invasive bladder cancer, radical cystectomy is the treatment of choice. Pioneers of laparoscopy have tried to remove the bladder in the early 90s. In the year 2000 Gill et al. managed to remove the bladder and reconstruct the urinary diversion completely laparoscopically for the first time. Since the implementation of the technique of laparoscopic radical prostatectomy in many American and European institutes, the development of technical instruments for laparoscopy is a milestone. With these instruments and with the knowledge of laparoscopic radical prostatectomy, the step to perform a laparoscopic radical cystectomy is not very far.

[Multimodal therapy of prostate cancer - 2 case reports]. / Multimodale Therapie des Prostatakarzinoms - 2 Fallberichte.

The importance of the carcinoma of the prostate is still increasing. It is important to have options such as multimodal therapy. In this article two selected case reports are presented. Treatment options such as surgery, hormonal and irradiation therapy as well as chemotherapy will be discussed. Each patient suffering from carcinoma of prostate should receive individual best therapy.

[Therapy of locoregional prostate cancer]. / Therapie des lokoregionären Prostatakarzinoms.

The importance of the carcinoma of the prostate is still increasing. It is important to know about the possibilities of diagnosis and treatment options. In this article risk factors, diagnosis and treatment options such as surgery, hormonal and irradiation therapy as well as "wait and see" strategy will be discussed. Each patient suffering from carcinoma of prostate should receive the therapy best suited to his needs.

[Interdisciplinary strategies for the treatment of bladder cancer]. / Interdisziplinäre Behandlungsstrategien des Harnblasenkarzinoms.

Muscle invasive bladder cancer is still an interdisciplinary problem for urologists, oncologists and radiotherapists. Our efforts should be on finding the right time for the right intervention such as radical cystectomy or chemotherapy and/or irradiation. New forms of diagnostics and therapies are now available, or at least in clinical trails, to make therapy more effective.