Lasers in Transurethral Enucleation of the Prostate-Do We Really Need Them.

The acronym EEP, coding for transurethral Endoscopic Enucleation of the Prostate, was introduced in 2016 by the European Association of Urology (EAU) guidelines panel on management of non-neurogenic male lower urinary tract symptoms (LUTS) and benign prostatic obstruction (BPO). Since then, a laser-based treatment, Holmium Laser Enucleation of the Prostate (HoLEP), and the current-based treatment of bipolar enucleation of the prostate (BipoLEP) are equally appreciated as valuable options for the management of benign prostatic obstruction (BPO). This was mainly inspired by the results of two meta-analyses on randomized controlled trials, comparing open prostatectomy with either Holmium Laser Enucleation of the Prostate (HoLEP) or bipolar enucleation of the prostate (BipoLEP). Prior to that, HoLEP was embraced as the only valid option for transurethral enucleation, although evidence for equivalence existed as early as 2006, but was not recognized due to a plethora of acronyms for bipolar energy-based treatments and practiced HoLEP-centrism. On the other hand, the academic discourse focused on different (other) laser approaches that came up, led by Thulium:Yttrium-Aluminum-Garnet (Tm:YAG) Vapoenucleation (ThuVEP) in 2009 and, finally, transurethral anatomical enucleation with Tm:YAG support (thulium laser enucleation of the prostate, ThuLEP) in 2010. Initially, the discourse on lasers focused on the different properties of lasers rather than technique or surgical anatomy, respectively. In and after 2016, the discussion ultimately moved towards surgical technique and accepting anatomical preparation as the common of all EEP techniques (AEEP). Since then, the unspoken question has been raised, whether lasers are still necessary to perform EEP in light of existing evidence, given the total cost of ownership (TCO) for these generators. This article weighs the current evidence and comes to the conclusion that no evidence of superiority of one modality over another exists with regard to any endpoint. Therefore, in the sense of critical importance, AEEP can be safely and effectively performed without laser technologies and without compromise.

Urinary Retention Due to Severe Pseudocystic Mucoid Degeneration of the Prostatic Matrix: A Rare Urologic Manifestation of Cystic Fibrosis.

Cystic fibrosis (CF) is an autosomal recessive genetic disease, which is characterized by the production of thick mucus in exocrine glands. The main cause for morbidity and mortality in CF patients is respiratory failure. The gastrointestinal system is also commonly affected. Urologic manifestations of CF include infertility and azoospermia, nephrolithiasis, and stress urinary incontinence. In this report, we describe a 33-year-old male, who presented with recurrent urinary retention due to prostatic enlargement despite his young age. After transurethral resection, the voiding problems resolved. Histopathological examination, however, revealed a severe pseudocystic mucoid degeneration of the prostatic matrix as a cause of his subvesical obstruction. Although these structural changes are most probably due to his underlying disease, detailed histologic features have not been described in the literature.

Radical cystectomy with orthotopic neobladder for invasive bladder cancer: a critical analysis of long-term oncological, functional, and quality of life results.

PURPOSE: The present contribution analyses long-term data regarding oncological, functional, and quality of life aspects of patients subjected to cystectomy due to malignancy with subsequent orthotopic bladder substitution. METHODS: A literature search was conducted to review literature published from 1887 until today. Oncological aspects, special considerations on female patients, quality of life, geriatric patients, and impact of minimally invasive surgery were also addressed and discussed. RESULTS: After more than three decades, orthotopic bladder substitution subsequent to radical cystectomy has stood the test of time by providing adequate long-term survival and low local recurrence rates. Compared to radical cystectomy, neither radiation nor chemotherapy, nor a combination of both, offer similar long-term results. Orthotopic bladder substitution does not compromise oncological outcome and can be performed with excellent results regarding functional and quality of life issues. Chronological age is generally not a contraindication for cystectomy. CONCLUSION: Orthotopic bladder substitution should be the diversion of choice both in men and in women, whenever possible. For orthotopic urinary diversion, a careful patient selection considering tumor extent, patient motivation, preoperative sphincter function, other local and systemic adverse confounding factors, and overall life expectancy must be taken into account. Minimally invasive techniques are promising concepts for the future, awaiting confirmation in larger patient cohorts.

Natural orifice (NOTES) transurethral sutureless radical prostatectomy with thulium laser support: first patient report.

INTRODUCTION: The aim of this descriptive study was to demonstrate the feasibility and safety of the first true transurethral sutureless radical prostatectomy for prostate cancer in humans using the NOTES technique. MATERIALS AND METHODS: A 77-year-old man with clinically localized bilateral prostate cancer (Gleason 3 + 4 = 7 in 80% of 12 biopsy cores) and a serum PSA level of 2.1 ng/ml underwent our first natural orifice transurethral radical thulium laser prostatectomy within toto organ retrieval via sectio alta. The surgical procedure is described. RESULTS: The procedure was completed successfully. Overall operation time was 312 min; laser time was 46 min with 151 KJ. Postoperative hemoglobin was 9.4 g/dl, and the hematocrit was 28%. A cystogram on the 7th postoperative day showed no signs of extravasation and the transurethral catheter was removed, and a flexible cystoscopy on the 9th day demonstrated a sufficient arbitrarily sphincter closure against irrigation flow. CONCLUSION: The presented descriptive report demonstrates that natural orifice transurethral radical thulium laser prostatectomy for prostate cancer is feasible and safe. Potential candidates include older patients with low-risk cancers and urinary obstruction. Further prospective reports are necessary to evaluate functional and oncological outcome for this innovative technique.

Solitary testicular metastasis from prostate cancer: a rare case of isolated recurrence after radical prostatectomy.

BACKGROUND: The prognosis of prostate cancer (PC) is mainly determined by the presence or absence of metastases. An isolated testicular metastasis of PC is rare. CASE REPORT: A 71-year-old patient with PC presented with an increased serum prostate-specific antigen (PSA) level of 2.07 ng/ml two and a half years after radical prostatectomy. Assuming a local recurrence in the prostatic fossa, local radiotherapy with 64.8 Gy was performed. Unfortunately, the PSA level rose again, accompanied by a swelling of the left testis approximately one month after radiotherapy. A unilateral orchiectomy was then performed, presenting a testicular metastasis of the PC. After orchiectomy, the PSA decreased to <0.07 ng/ml. Two years later, the patient is still tumour-free. CONCLUSION: Careful clinical follow-up of patients with rising serum PSA level is important to recognize isolated, locally treatable metastastic disease. In particular, rare metastatic sites such as the testis or the epididymis should be taken into account before treatment of biochemical recurrence is initiated.

The periprostatic autonomic nerves--bundle or layer?

BACKGROUND: The functional outcome of a nerve-sparing radical prostatectomy (RP) depends on the knowledge of autonomic nerve distribution in correlation to the prostate. OBJECTIVE: Recent literature has focused predominantly on the anterior prostate; this study evaluates the nerve distribution on the entire prostate, using a two-dimensional approach. DESIGN, SETTING, AND PARTICIPANTS: From 17 non-nerve-sparing (NS) RP specimens, 77 whole mounted serial sections were immunostained with PGP9.5 and analyzed. INTERVENTION: Each prostate half was divided into 12 sectors (three levels: apex, mid-part, base; four courses: anterior, anterolateral, posterolateral, posterior). MEASUREMENTS: The extracapsular nerves were counted and classified by size (>200microm or

Initial clinical experience with full-length metal ureteral stents for obstructive ureteral stenosis.

OBJECTIVES: Long-term ureteral stenting is used to ensure urinary drainage if a reconstructive approach or a release of an extrinsic obstruction is not possible. In this contribution, a long-term experience with a new full-length, metal indwelling stent is presented. METHODS: Fourteen patients with ureteral obstruction received full metal indwelling stents in 18 collecting systems (benign disease in 5 and malignant disease in 13). Stent placement was performed cystoscopically under fluoroscopic guidance. Follow-up was done every 3 months with ultrasonographic examination, creatinine levels, and a visual analog pain score. RESULTS: Eight stents were removed, whereas eight are still in situ. One patient without stent-related problems died because of progressive rectal cancer 9 months after bilateral stent insertion. Mean stent duration (8 stents still in situ) is 8.6 months, whereas mean stent duration for benign and malignant disease is 11.8 (median 13) and 7.3 (median 6) months, respectively (p<0.05). All removed stents were extracted endoscopically without any problems and had no incrustation except two. Neither migration nor mechanical damage was observed. CONCLUSION: This novel stent is easy to insert and remove. It is an option for patients in which a surgical reconstruction of the obstructed ureter is not possible. Stents have been developed further and are now available in various lengths. This might result in a reduction of problems associated with inadequate stent length and should increase patient comfort and stent durability.

Surgical approach in patients with T4 bladder cancer as primary treatment: Disaster or option with improved quality of life.

OBJECTIVES: Whereas local control is often insufficient in conservative management of T4 bladder cancer, neoadjuvant chemotherapy delays definite treatment, which could result in increased therapy-associated morbidity and mortality during the course of the disease. Primary cystectomy has been reported to be associated with a high complication rate and unsatisfactory clinical efficacy. Herein, we report postoperative outcome in 21 T4 bladder cancer patients subjected to primary cystectomy. MATERIALS AND METHODS: Twenty-one patients underwent radical cystectomy for T4 (T4a/b: 14 and seven cases, respectively) bladder cancer. At the time of surgery, eight patients had regional lymph node metastases (N2: 6; N3: 2). The average age was 64 (52-77) years (>/=70 years: n = 7). The postoperative follow-up was 13 (1-36) months for the whole group. RESULTS: Mean duration of postoperative hospitalization was 19 (11-50) days. Whereas 10 patients received no intra - or postoperative blood transfusions, an average number of 3 (1-7) blood units were administered in the remaining cases. The mean postoperative hemoglobin value of patients not receiving any blood transfusions was 10 (8.5 - 11.4) g/dl. Major therapy-associated complications were paresthesia affecting the lower extremities (n = 3) as well as insignificant pulmonary embolism, enterocutaneous fistulation and acute renal failure in one patient, respectively. At the time of data evaluation, 11 patients were still alive after a follow-up of 20 (6-36) months. Four patients >/=70 years at the time of cystectomy were still alive 11, 11, 22 and 31 months following surgery, respectively. CONCLUSION: Primary cystectomy for T4 bladder cancer is a technically feasible approach that is associated with a tolerable therapy-related morbidity/mortality. Additionally, a satisfactory clinical outcome is observed even in a substantial number of elderly patients.

A newly designed amplatz sheath decreases intrapelvic irrigation pressure during mini-percutaneous nephrolitholapaxy: an in-vitro pressure-measurement and microscopic study.

BACKGROUND AND PURPOSE: In recent years, mini-percutaneous nephrolitholapaxy (mini-PCNL) has gained popularity because of its reduced invasiveness. To improve clinical outcomes further, research is ongoing in selected centers. Important areas of interest include extravasation into the retroperitoneal space, acute absorption syndrome, and septicemia. The aim of this experimental study was to test a new 18F nephroscope sheath specially designed to decrease intrapelvic pressure during mini-PCNL whatever the irrigation pressure. In addition, the hydrodynamic effects of this device can be used for suction and removal of the stone fragments, in contrast to a standard Amplatz sheath. MATERIALS AND METHODS: In a fresh, perfused cadaveric porcine kidney model, the new sheath was compared with a conventional sheath (control) with closed and open Luer-Lok outflow under increasing irrigation pressure. Intrarenal pressure peaks were measured with a urodynamic workstation. The irrigation fluid was marked with an ink that stains only endoluminal surfaces, and a post-measurement histopathologic work-up was performed to evaluate the changes on a morphologic level. RESULTS: Closing of the control sheath resulted in an increase in the intrapelvic pressure to a maximum of 136 cm H2O. Using the new sheath with a constant output flow made possible by its open proximal end, the maximal intrapelvic pressure remained low at 20 cm H2O, even when the inflow pressure reached 125 cm H2O. The ink distribution on the hematoxylin and eosin-stained slides reflected the results of the pressure measurements. CONCLUSIONS: Newly designed nephroscope sheaths with an open proximal end, such as the one described here, decrease the intrapelvic pressure compared with a closed outflow system. As a result, strict fluid control during the intervention is not necessary.

Steerable antegrade stenting: a new trick of the trade.

INTRODUCTION: Whereas a retrograde attempt to insert an indwelling stent is performed in lithotomy position, usually renal access is gained in a prone position. To overcome the time loss of patient repositioning, a renal puncture can be performed in a modified lithotomy position with torqued truncus and slightly elevated flank. There is a two-fold advantage of this position: transurethral and transrenal access can be obtained using a combined approach. In the present study, this simple technique is used to position a floppy guide wire through a modified needle directly through the renal pelvis into the ureter. MATERIALS AND METHODS: The kidney is punctured in the modified lithotomy position under sonographic control using an initial three-part puncture needle. A floppy tip guide-wire is inserted into the collecting system via the needle after retrieving the stylet. The retracted needle is bent at the tip while the guide-wire is secured in the needle and the collecting system. The use of the floppy tip guide-wire helps to insert the curved needle back into the kidney pelvis, which becomes the precise guidance for the now steerable wire. The desired steerable stent is positioned under radiographic control in a retrograde fashion over the endoscopically harbored tip of the guide-wire. Two patient cohorts (newly described method and conventional method) were compared. RESULTS: The presented steering procedure saves 16.5 mean minutes compared to the conventional antegrade stenting and 79.5 Euros compared to the control group. CONCLUSION: The described combined antegrade-retrograde stent placement through a bent three-part puncture needle results in both clinical superiority (OR time, success rate) and financial benefits.

Morphologic, functional, and metabolic magnetic resonance imaging-guided prostate biopsy in a patient with prior negative transrectal ultrasound-guided biopsies and persistently elevated prostate-specific antigen levels.

A 65-year-old patient was examined with [11C]-choline positron emission tomography-computed tomography and magnetic resonance imaging (MRI) for possible tumor detection after two negative sessions of transrectal ultrasound-guided prostate biopsy and persistently elevated prostate-specific antigen levels for 27 months. Choline positron emission tomography revealed a small and circumscribed pathologic tracer uptake in the right dorsal peripheral gland. Whereas T2-weighted MRI and high b-value diffusion-weighted imaging were able to reproduce this suspicious area, proton MR spectroscopy showed no significant increase of the amplitude of choline-containing compounds. Magnetic resonance imaging-guided prostate biopsy was successfully performed. All specimens taken from the lesion showed a Gleason 5 tubular adenocarcinoma with low proliferative activity.

Steerable antegrade stenting: a new trick of the trade

INTRODUCTION: Whereas a retrograde attempt to insert an indwelling stent is performed in lithotomy position, usually renal access is gained in a prone position. To overcome the time loss of patient repositioning, a renal puncture can be performed in a modified lithotomy position with torqued truncus and slightly elevated flank. There is a two-fold advantage of this position: transurethral and transrenal access can be obtained using a combined approach. In the present study, this simple technique is used to position a floppy guide wire through a modified needle directly through the renal pelvis into the ureter. MATERIALS AND METHODS: The kidney is punctured in the modified lithotomy position under sonographic control using an initial three-part puncture needle. A floppy tip guide-wire is inserted into the collecting system via the needle after retrieving the stylet. The retracted needle is bent at the tip while the guide-wire is secured in the needle and the collecting system. The use of the floppy tip guide-wire helps to insert the curved needle back into the kidney pelvis, which becomes the precise guidance for the now steerable wire. The desired steerable stent is positioned under radiographic control in a retrograde fashion over the endoscopically harbored tip of the guide-wire. Two patient cohorts (newly described method and conventional method) were compared. RESULTS: The presented steering procedure saves 16.5 mean minutes compared to the conventional antegrade stenting and 79.5 Euros compared to the control group. CONCLUSION: The described combined antegrade-retrograde stent placement through a bent three-part puncture needle results in both clinical superiority (OR time, success rate) and financial benefits.

The rationale for radical cystectomy as primary therapy for T4 bladder cancer.

Treatment of T4 bladder cancer patients remains a clinical challenge. Conservative management is often insufficient regarding local control, neoadjuvant chemotherapy delays definite treatment while leading to increased therapy-associated morbidity and mortality during the course of the disease. Primary cystectomy has also been reported to be associated with a high complication rate and unsatisfactory clinical efficacy. Herein, we report postoperative outcome, including therapy-related complications, in 20 T4 bladder cancer patients subjected to primary cystectomy. Twenty patients underwent radical cystectomy for T4 bladder cancer. At the time of surgery, 8 patients had regional lymph node metastases. The median postoperative follow-up was 13 months for the whole group. Mean duration of postoperative hospitalization was 19 days. Ten patients received no intra- or postoperative blood transfusions, whereas an average number of 3 blood units were administered in the remaining cases. Major therapy-associated complications were paresthesia affecting the lower extremities (n = 3) as well as insignificant pulmonary embolism, enterocutaneous fistulation and acute renal failure in one patient, respectively. At the time of data evaluation, 11 patients were still alive after a follow-up of 20 months. Four patients >or=70 years at the time of cystectomy were still alive after 11, 22 and 31 months following surgery, respectively. The current data demonstrate primary cystectomy for T4 bladder cancer as a technically feasible approach that is associated with a tolerable therapy-related morbidity. Additionally, satisfying clinical outcome is observed even in a substantial number of elderly patients.

Introducing a new sealant applicator for easy, safe, and quick closure of a mini-percutaneous nephrolitholapaxy access tract.

PURPOSE: To achieve better hemostasis after mini-percutaneous nephrolitholapaxy (mini-PCNL), we developed a new application device that can be used to close the renal-access tract with gelatin matrix hemostatic sealant (GMHS). PATIENTS AND METHODS: After mini-PCNL was performed on 11 patients, a Double-J ureteral stent was placed antegrade. After retraction of the 18F Amplatz sheath out of the collecting system under vision without irrigation, the urothelium collapsed. The 15F metal applicator with a 10F working channel was then inserted and GMHS injected during further retraction of both the device and the Amplatz sheath. The skin was closed with Steri-strips. RESULTS: The renal parenchymal tract of the mini-PCNL can be sealed in 15 to 50 seconds. Postoperatively, no urinoma was observed. All patients had an uneventful follow-up. CONCLUSION: Closing the track of the mini-PCNL with the new application device and GMHS is a safe, easy, and quick alternative to the common nephrostomy tube.

Post-chemotherapy laparoscopic retroperitoneal lymph-node dissection in testis cancer patients.

BACKGROUND AND PURPOSE: Retroperitoneal lymph node dissection (RPLND) is still the most sensitive and specific method for the detection of malignant tumor and mature teratoma in stage II nonseminomatous testicular carcinoma after chemotherapy. Acceptance of this operation, however, has decreased because of the morbidity associated with the open approach. To reduce the morbidity and to improve the acceptance of RPLND, laparoscopy has been introduced. In this study, we describe our experiences with laparoscopic RPLND for stage II testicular carcinoma after chemotherapy. METHODS: Sixteen patients underwent 17 laparoscopic RPLND after chemotherapy for clinical stage IIA-III nonseminomatous testicular cancer. Patients with post-chemotherapy residual masses >1 cm and normalization of tumor markers were considered for the procedure. Our dissection field included the resection of the residual tumor as well as the ipsilateral template. RESULTS: Laparoscopic RPLND was completed in all patients. Operative time ranged from 125 to 370 minutes (mean 240 +/- 56 min). No transfusions were required, and no intra- or postoperative complications occurred because of the procedure. A bleomycin-induced interstitial pneumonia developed in one patient. After a mean follow-up period of 26 +/- 11 months (range 4 to 38), two disease recurrences were observed. CONCLUSION: Laparoscopic RPLND after chemotherapy is a feasible and oncologically safe procedure. However, the technique is challenging and should only be performed in selected patients with low residual tumor volume.

Size does matter: 1.5 Fr. stone baskets almost double irrigation flow during flexible ureteroscopy compared to 1.9 Fr. stone baskets.

With a new generation of flexible ureterorenoscopes, a new area in stone management is emerging. Limitation of vision with these new instruments is often caused by insufficient irrigation flow, especially when using instruments like stone baskets, resulting from partial obstruction of the working and irrigation channel with these instruments. Empirically, new available smaller stone baskets seem to dramatically improve irrigation and therefore vision in clinical use. The goal of this study was to show objective differences in basket diameters and flow rates in an in vitro setting. Diameters and irrigation flows in flexible ureterorenoscopes depending on different sizes of stone baskets (Fr. 1.5-1.7-1.9-2.2-2.4-3.0) and different deflections were measured. The measured diameter of the baskets varied within the first 20 cm and the true measured size varied from the manufacturer's specified size to a different extent. The new generation of 1.5 and 1.7 Fr. baskets improved irrigation flow, even compared to the smallest commonly used baskets, up to 68%. Interestingly, deflection did not influence irrigation flow. This study confirmed the subjective impression of inadequate description of relevant basket diameters as well as that of a significant improvement of irrigation flow with the newest generation of stone baskets with smaller diameters.

Closing the tract of mini-percutaneous nephrolithotomy with gelatine matrix hemostatic sealant can replace nephrostomy tube placement.

OBJECTIVES: To investigate the outcomes using gelatine matrix hemostatic sealant to close the tract after mini-percutaneous nephrolithotomy (mini-PCNL), resulting in a tubeless setting. METHODS: After complete stone removal after mini-PCNL, a double-J ureteral stent was placed in an antegrade manner. After withdrawing the 17F Amplatz sheet from the collecting system under direct vision without irrigation, the urothelium collapsed. While retracting the sheet further, the gelatine matrix hemostatic sealant was injected. The skin incision was closed with glue. An ultrasound examination was performed on the first postoperative day to exclude the presence of urine extravasation. RESULTS: Mini-PCNL was performed in 11 patients, either as a primary, small stone, single-access procedure or as a second-look mini-PCNL because of small residual fragments after extracorporeal shock wave lithotripsy. The time to seal the mini-PCNL tract through the kidney parenchyma was 2 to 5 minutes. The mean operative time was 79 minutes. In the first 5 cases, intravenous urography was performed in addition to ultrasonography and demonstrated an intact collecting system. The subsequent procedures demonstrated similar findings, with the exception of 1 case of temporary paravasation. In all other patients, the catheter was removed on the first postoperative day. Ten of 11 patients had an uneventful follow-up until removal of the double-J catheter. No major complications were observed. CONCLUSIONS: Closing the tract of the mini-PCNL with gelatine matrix hemostatic sealant is a safe and fast alternative and provides the option of discharging the patient in good condition without the commonly used nephrostomy tube.

Comparison of flexible grasping forceps and stone basket for removal of retracted ureteral stents.

BACKGROUND: Ureteral-stent dislocation can occur either during positioning or postoperatively. Grasping the distal end of the stent and removing it depends on the angulation between the extraction device and the stent, the size and length of the instrument, and the force of the branches and resistance of the dislocated stent. PATIENTS AND METHODS: Six cases of challenging stent removal are presented, and details of the surgical technique are described. By in-vitro testing, we investigated the deflection of flexible cystoscopes and ureteroscopes using forceps or a four-wire stone basket, the ability to grasp a stent depending on the angle between the stent axis and the extraction device, and the force that can be applied on the stent with the different devices. RESULTS: In all cases, it was possible to extract the stent with a stone basket. In an in-vitro setting, maximum extraction forces, measured with a macro scale, were 1.3 kg (cystoscopic forceps) and 0.4 kg (ureteroscopic forceps) until the forceps slipped off the stent. In the same setting, a rupture of the wires of the 1.9F stone basket occurred at 0.8 kg, whereas with a 2.4F basket, a force of 1.9 kg led to rupture of the stent, leaving the basket intact. CONCLUSIONS: Using a stone basket instead of grasping forceps in difficult cases of dislocated stents opens new possibilities for their cystoscopic and ureteroscopic removal. Because the superiority of the basket is counterbalanced by its higher costs, we suggest the basket extraction method only in difficult cases.