[Urinary diversion in old patients (80+ years)]. / Harnableitung beim alten Patienten (80+).

With increasing life expectancy there is also an increased need for the management of older (≥ 80 years) patients with the diagnosis of muscle-invasive bladder cancer. Radical cystectomy with urinary diversion is the state of the art treatment (with neoadjuvant chemotherapy, as long as the patient is fit enough). Choosing the best urinary diversion with respect to morbidity compared to functionality and quality of life remains a challenge in these patients. Physical age alone is not decisive for making a decision. A thorough preoperative assessment of medical features, physical and cognitive impairments is more important. Older patients are generally provided with an ileal conduit as an incontinent urinary diversion, as the intervention involves reduced operating times and complexity compared to continent urinary diversions; however, in the case of good health status with an adequate life expectancy and sufficient compliance, continent diversions may be considered even in aged candidates. In the case of multimorbid patients with a high perioperative risk, ureterostomy with permanent ureteric stents is an important alternative. Most importantly, a thorough preoperative counselling enables patients to reach an informed decision.

[Transurethral resection of bladder tumors (TURBT)]. / Transurethrale Resektion von Blasentumoren (TUR-B).

Transurethral resection of bladder tumors (TURBT) is the standard of care for the diagnostics and primary treatment of bladder tumors. These are removed by fragmentation using loop diathermy. The resection area is coagulated for hemostasis. An important aspect is always a complete resection with an adequate amount of detrusor muscle in the specimen. Postoperative intravesical instillation of single-shot chemotherapy has been proven to reduce recurrence rates. Methods for improved tumor visualization (particularly photodynamic diagnostics) are used to enhance tumor detection rates particularly in multifocal tumors or carcinoma in situ (CIS). Thus, recurrence and progression rates can be reduced. Depending on the histological examination of the TURBT specimen, follow-up treatment for non-muscle invasive bladder tumors are adjuvant instillation treatment using chemotherapy or Bacillus Calmette-Guérin (BCG), second look TURBT and early cystectomy or for muscle invasive bladder tumors, radical cystectomy or (oncologically subordinate) trimodal treatment with renewed TURBT, radiotherapy and chemotherapy are indicated. Possible complications of TURBT include bleeding with bladder tamponade, extraperitoneal or intraperitoneal bladder perforation and infections of the urogenital tract.

[Safety and efficacy of en bloc vs. conventional transurethral resection of bladder tumors: a meta-analysis and systematic review]. / Sicherheit und Effizienz der en bloc vs. konventionellen transurethralen Resektion von Blasentumoren: eine Metaanalyse und systematic Review.

BACKGROUND: En bloc tumor resection of bladder tumors (ERBT) is a novel alternative procedure to conventional resection of bladder tumor (cTURBT), which might help to address common problems of the standard method, such as inadequate detrusor muscle in specimens, high re-resection rates and high recurrence rates. OBJECTIVE: To analyze current data on ERBT in efficacy and safety compared to cTURBT. DATA SOURCES: PubMed. STUDY SELECTION: Two independent authors identified trials based on keywords and inclusion criteria. A third author was consulted in case of discrepancies. Screening keywords: ERBT, en bloc transurethral resection of bladder tumor, TURBT en bloc. A meta-analysis of 13 studies was performed. The effect size was estimated based on odds ratios and mean differences including their corresponding two-sided 95% confidence intervals. DATA SYNTHESIS: The analyzed studies comprised a homogenous collective in terms of tumor size, tumor multiplicity and tumor stage. Operation time did not significantly differ between the methods. Differences were observed in hospitalization and catheterization time in favor of ERBT. Reported complications did not show clear differences. There was significantly more detrusor muscle in the specimens in the ERBT group. No significant differences were found in recurrence up to 2 years of follow-up. CONCLUSION: ERBT is a safe alternative to conventional TURBT with promising features regarding effective resection of detrusor muscle. More standardized data on recurrence rates, different resection modalities and resection margin results are needed.

[Novel surgical techniques for treatment of benign prostatic hyperplasia]. / Neue operative Techniken zur Therapie des benignen Prostatasyndroms.

In recent years new surgical techniques to treat benign prostatic hyperplasia have been introduced into urological practice and evaluated in clinical studies. Complications of standard procedures, e.g. transurethral resection of the prostate (TURP), can be avoided while maintaining equivalent clinical outcomes. The main goal is preservation of erectile and ejaculatory function. Furthermore, outpatient treatment associated with a rapid patient recovery would be desirable. This article presents the course of the interventions, the mechanisms of action and current clinical evidence for novel mechanical approaches of recanalization, water-based ablation as well as prostate artery embolization. Initial study results partially indicate that in the future practically all patients can be offered an individualized surgical technique, which provides optimal symptomatic and functional improvements with a minimized risk of complications.

Etiology of Appendicitis in Children: The Role of Bacterial and Viral Pathogens.

BACKGROUND: Although acute appendicitis is the most common cause for abdominal surgery in children, its etiology is still largely unknown. The aim of this study was to evaluate the role of bacterial and viral pathogens for the etiology of appendicitis in children. METHODS: Between 2000 and 2010, 277 children underwent appendectomy in our institution. On this collective, a retrospective study was performed on to identify the presence of bacterial or viral pathogens. RESULTS: Intraoperatively, 39% of cases showed acute, 9% of cases chronic, and 41% of cases ulcerous inflammation. Bowel perforation was found in 7% of cases and four percent of the children had no inflammation of the appendix at all. Escherichia coli was the predominant bacterium with an incidence of 27.4%, followed by streptococci (9.8%). Concerning viral pathogens, adenovirus was the most common with an incidence of 5.4% followed by rotavirus (4.7%). Significant correlations between histopathological findings and present pathogens were found: in cases of bowel perforation there were significantly more infections with E. coli bacteria (32.2%, p < .001), streptococci (12.2%, p < 0.001), and Pseudomonas aeruginosa (6.7%, p < .001) whereas chronic inflammations were accompanied with a significantly elevated rate of yersinia infections (2.5%, p = .016). Acute inflammations were significantly more often associated with campylobacter (1.7%, p = .011) and oxyures infections (6.1%, p < .001). In relation to the patients' age, a significant accumulation of different pathogens was observed. CRP- and leukocyte counts showed differences between viral and bacterial inflammations. CONCLUSIONS: Our data indicates that appendicitis in children might be triggered by bacterial and viral pathogens and that the type of pathogen directly correlates with patient age, type of inflammation, and level of inflammation values. To confirm and further evaluate these findings, additional studies need to be conducted.

Analysis of adhesion formation of a new elastic thermoplastic polyurethane (TPU) mesh in comparison to polypropylene (PP) meshes in IPOM position.

BACKGROUND: Postsurgical adhesions severely affect the patients' quality of life causing various complications like bowel obstruction or chronic pain. Especially the implantation of alloplastic prostheses in IPOM position for hernia repair carries a high risk of adhesion formation due to the close contact between mesh and viscera. The extent of adhesions mainly depends on the type and textile characteristics of the implanted mesh. The aim of this study was to examine the degree of adhesion formation of a newly developed, elastic thermoplastic polyurethane (TPU) mesh in comparison to polypropylene (PP) meshes in IPOM position in a rabbit model. METHODS: Sixteen female chinchilla rabbits were laparoscopically operated. Two different meshes were placed to the left and the right lower abdominal wall in IPOM position in each rabbit. After 7 or 21 days, midline laparotomy was performed, the degree of adhesion formation was examined by the Diamond score and mesh elongation was measured under a force of 3N. Finally, the abdominal walls were explanted for immunohistochemical and histopathological investigations. RESULTS: TPU meshes showed significantly lower Diamond scores than PP meshes. After explantation, mesh elongation of the TPU mesh was significantly larger than expansion of PP under a force of 3N. Thus, the TPU mesh preserved its elastic properties after 7 and 21 days. The amount of CD68 positive, Ki67 positive and apoptotic cells within the granuloma around the fibers did not show significant differences between the study groups. CONCLUSIONS: The newly developed TPU mesh seems to reduce peritoneal adhesion formation in IPOM position in a rabbit model compared to PP meshes after 7 and 21 days. Immunohistochemistry did not reveal differences in biocompatibility of the two meshes used.