Lateral lumbar and thoracic interbody fusion (LLIF) for thoracolumbar spine trauma (Trauma LLIF): A single-center, retrospective observational cohort study.

Background: Pain, disability and progressive kyphosis is a common problem after traumatic injury of the thoracolumbar (TL-) junction. Surgical treatment may include long-segment posterior or short-segment anterior-posterior fusion. We aim to report our experience with the application of short-segment posterior instrumented fusion with anterior column support using lateral lumbar or thoracic interbody (LLIF) cages. Methods: In this retrospective, single-center observational cohort study we included consecutive patients treated surgically for traumatic injury of the TL-junction (Th10/11-L2/3) by posterior instrumentation/fusion and LLIF. We measured segmental kyphosis, complications, and outcomes until last follow-up (about 3 years postoperative). Results: We identified 61 patients (mean age 39.0 years [SD 13.3]; 23 females [37.7%]) with A3 fractures without (n=48; 78.7%) or with additional sagittal split component n=11; 18.0%. Additional posterior tension band injury was present in n=26 (42.6%). The affected levels of injury were Th12/L1 in n=25 (41.0%) and Th11/12 in n=22 (36.1%). The segmental kyphotic angle was 14.6° (6.7°) preoperative and remained significantly reduced at all times of follow-up at discharge (5.4°±5.5°; p<.001), at 90 days (7.2°±5.5°; p<.001), after partial hardware removal (7.2°±6.0°; p<.001) and at last follow-up (8.1°±6.3°; p<.001). We noticed a tendency for less progression of kyphosis in the group with 2-staged, compared to single-staged bisegmental surgery (mean difference (MD) 3.1° after partial hardware removal, p=.064). During follow-up, n=11 experienced complications (18%), n=58 (95.1%) had an excellent or good outcome and solid fusion was noticed in n=60 (98.4%). Conclusions: "Trauma LLIF" should be considered as possibility for short-segment anterior-posterior fusion for injuries of the TL- junction. We observed most reproducible and long-lasting kyphosis reduction with a temporary bisegmental, 2-staged procedure resulting in monosegmental fusion (posterior instrumentation/fusion with delayed LLIF and partial hardware removal to release the noninjured caudal motion segment).

Implantation of C2 prosthesis with dorsal fusion C0-C4 due to pathologic C2 fracture. Case report and literature review.

INTRODUCTION: Pathological destruction of the axis vertebra leads to a highly unstable condition in an upper cervical spine. As surgical resection and anatomical reconstruction of the second cervical vertebrae represents a life threatening procedure, less radical approaches are preferred and only few cases of C2 prosthesis are described in literature. CASE DESCRIPTION: The focus of this case report is a 21-year-old man with a pathological fracture of C2 managed primarily surgically with the C1-C3 dorsal fusion. Due to the progression of giant cell tumor and destruction of the axis vertebra, C2 prosthesis through anterior approach and dorsal occipito-cervical fusion C0-C4 were performed. Postoperative infection was managed surgically with a 2-staged dorsal debridement, ostheosynthesis material change and autologous bone graft. After a 4 week-intravenous therapy with the ceftriaxone in combination with the amoxicillin/clavulanate, followed by 12 week per oral therapy with amoxicillin/clavulanate in combination with ciprofloxacin, the complete recovery of the infection was achieved. Radiotherapy was initiated 2 months after the last revision surgery and the patient showed a good clinical outcome with stable construct at a 1 year follow-up. A review of literature of all reported C2 prosthesis cases was performed CONCLUSION: C2 prosthesis allows a more radical resection in pathological processes involving the axis vertebra. Combined with the posterior fusion, immediate stability is achieved. Anterior surgical approach is through a highly unsterile oral environment which presents a high-risk of postoperative infection.

Nonlinear Finite Element Calculations of Layered SAW Resonators.

In this work the nonlinear behavior of layered SAW resonators is studied with the help of Finite Element (FE) computations. The full calculations depend strongly on the availability of accurate tensor data. While there are accurate material data for linear computations, the complete sets of higher-order material constants, needed for nonlinear simulations, are still not available for relevant materials. To overcome this problem, scaling factors were used for each available nonlinear tensor. The approach here considers piezoelectricity, dielectricity, eletrostriction and elasticity constants up to fourth order. These factors act as a phenomenological estimate for incomplete tensor data. Since no set of fourth order material constants for LiTaO3 is available, an isotropic approximation for the fourth order elastic constants was applied. As a result, it was found that the fourth order elastic tensor is dominated by one fourth order Lamé constant. With the help of the FE model, derived in two different, but equivalent ways, we investigate the nonlinear behavior of a SAW resonator with a layered material stack. The focus was set to third order nonlinearity. Accordingly, the modeling approach is validated using measurements of third order effects in test resonators. In addition, the acoustic field distribution is analyzed.

Spondylodiscitis due to anaerobic bacteria Veillonella parvula: Case report and literature review.

BACKGROUND: While pyogenic spondylodiscitis due to Gram-positive aerobic bacteria and its treatment is well known, spondylodiscitis caused by anaerobic Gram-negative pathogen is rare. In particular, the spondylodiscitis caused by Veillonella species is an absolute rarity. Thus no established management recommendations exist. CASE DESCRIPTION: A case report of a 79-year-old man with spondylodiscitis caused by Veillonella parvula with intramuscular abscess collection managed conservatively with stand-alone antibiotic therapy without a spinal stabilization procedure. A review of literature of all reported spondylodiscitis caused by Veillonella species was performed. After 3 week-intravenous therapy with the ceftriaxone in combination with the metronidazole followed by 3 weeks per oral therapy with amoxicillin/clavulanate, the complete recovery of the patient with the V. parvula infection was achieved. CONCLUSION: Treatment of the spondylodiscitis caused by Veillonella species should contain a beta-lactam with beta-lactamase inhibitor or third-generation cephalosporine. Six weeks of treatment seem to be sufficient for the complete recovery of the patient.

Differentiating epidural fibrosis from disc herniation on contrast-enhanced and unenhanced MRI in the postoperative lumbar spine.

OBJECTIVE: To determine diagnostic confidence and inter-observer/intra-observer agreement in differentiating epidural fibrosis from disc herniation and lumbar spinal stenosis parameters on magnetic resonance images (MRI) in postoperative lumbar spines with (Gad-MRI) and without (unenhanced MRI) intravenous gadolinium-based contrast agent. SUBJECTS AND METHODS: N = 124 lumbar spine MRI examinations of four groups were included: 1-6 months, 7-18 months, 19-36 months, more than 37 months between lumbar spine surgery and imaging. Two radiologists evaluated Gad-MRI and unenhanced MRI: diagnostic confidence was determined as confident or unconfident. Inter-observer and intra-observer agreement were assessed in differentiating epidural fibrosis from disc herniation and for lumbar spinal stenosis parameters on MRI. Fisher's exact test and Cohen's kappa served for statistics. RESULTS: Diagnostic confidence in differentiating epidural fibrosis from disc herniation was significantly higher on Gad-MR images compared with unenhanced MRI at 1-18 months for observer 1 and at 1-6 months postoperatively for observer 2 (p values: 0.01-0.025). Inter-observer agreement at 1-6 months postoperatively for identification of epidural fibrosis was higher on Gad-MRI (kappa values: 0.53 versus 0.24). Inter-observer and intra-observer agreement for identification of disc herniation and for assessment of lumbar spinal stenosis parameters revealed inconsistent data, without a trend for higher inter-observer or intra-observer agreement on Gad-MRI compared with unenhanced MRI (kappa values: 0.17-0.75). CONCLUSION: Gad-MR images compared with unenhanced MRI improved diagnostic confidence and agreement in differentiating epidural fibrosis from disc herniation for both observers in the first 6 months and for one observer in the first 18 months after lumbar spine surgery. After 18 months, Gad-MR images compared with unenhanced MRI did neither improve confidence nor agreement.

A novel organotypic 3D sweat gland model with physiological functionality.

Dysregulated human eccrine sweat glands can negatively impact the quality-of-life of people suffering from disorders like hyperhidrosis. Inability of sweating can even result in serious health effects in humans affected by anhidrosis. The underlying mechanisms must be elucidated and a reliable in vitro test system for drug screening must be developed. Here we describe a novel organotypic three-dimensional (3D) sweat gland model made of primary human eccrine sweat gland cells. Initial experiments revealed that eccrine sweat gland cells in a two-dimensional (2D) culture lose typical physiological markers. To resemble the in vivo situation as close as possible, we applied the hanging drop cultivation technology regaining most of the markers when cultured in its natural spherical environment. To compare the organotypic 3D sweat gland model versus human sweat glands in vivo, we compared markers relevant for the eccrine sweat gland using transcriptomic and proteomic analysis. Comparing the marker profile, a high in vitro-in vivo correlation was shown. Carcinoembryonic antigen-related cell adhesion molecule 5 (CEACAM5), muscarinic acetylcholine receptor M3 (CHRM3), Na+-K+-Cl- cotransporter 1 (NKCC1), calcium-activated chloride channel anoctamin-1 (ANO1/TMEM16A), and aquaporin-5 (AQP5) are found at significant expression levels in the 3D model. Moreover, cholinergic stimulation with acetylcholine or pilocarpine leads to calcium influx monitored in a calcium flux assay. Cholinergic stimulation cannot be achieved with the sweat gland cell line NCL-SG3 used as a sweat gland model system. Our results show clear benefits of the organotypic 3D sweat gland model versus 2D cultures in terms of the expression of essential eccrine sweat gland key regulators and in the physiological response to stimulation. Taken together, this novel organotypic 3D sweat gland model shows a good in vitro-in vivo correlation and is an appropriate alternative for screening of potential bioactives regulating the sweat mechanism.

Incidence and risk factors for early adjacent vertebral fractures after balloon kyphoplasty for osteoporotic fractures: analysis of the SWISSspine registry.

PURPOSE: The SWISSspine registry (SSR) was launched in 2005 to assess the safety and effectiveness of balloon kyphoplasty (BKP). In the meantime, repeated reports on high rates of adjacent vertebral fractures (ASF) after BKP of vertebral insufficiency fractures were published. The causes for ASF and their risk factors are still under debate. The purpose of this study was to report the incidence and potential risk factors of ASF within the SSR dataset. METHODS: The SSR data points are collected perioperatively and during follow-ups, with surgeon- and patient-based information. All patients documented with a monosegmental osteoporotic vertebral insufficiency fracture between March 2005 and May 2012 were included in the study. The incidence of ASF, significant associations with co-variates (patient age, gender, fracture location, cement volume, preoperative segmental kyphosis, extent of kyphosis correction, and individual co-morbidities) and influence on quality of life (EQ-5D) and back pain (VAS) were analyzed. RESULTS: A total of 375 patients with a mean follow-up of 3.6 months was included. ASF were found in 9.9 % (n = 37) and occurred on average 2.8 months postoperatively. Preoperative segmental kyphosis >30° (p = 0.026), and rheumatoid arthritis (p = 0.038) and cardiovascular disease (p = 0.047) were significantly associated with ASF. Furthermore, patients with ASF had significantly higher back pain at the final follow-up (p = 0.001). No further significant associations between the studied co-variates and ASF were seen in the adjusted analysis. CONCLUSIONS: The findings suggest that patients with a preoperative segmental kyphosis >30° or patients with co-morbidities like rheumatoid arthritis and a cardiovascular disease are at high risk of ASF within 6 months after the index surgery. In case of an ASF event, back pain levels are significantly increased. LEVEL OF EVIDENCE: IV.

Mechanisms of tracheal filling in insects.

Insects exchange respiratory gases primarily using tracheal systems that are filled with gas. However, in different developmental and environmental circumstances, liquid can occupy the tracheal system, which can significantly impair its respiratory function. Insects therefore use a suite of mechanisms for tracheal filling, which is the process of replacing tracheal liquids with gas. We review these mechanisms for liquid removal and gas filling. By integrating recent molecular work with older physiological literature, we show that liquid removal likely involves active ion transport in the whole tracheal system. Gas filling reveals fascinating interactions between geometry, surface chemistry of the tracheal walls, the tracheal liquid, and dissolved gases. The temporal proximity to moulting allows for potentially complex interdependencies between gas filling, moult-associated hormone signaling, and cuticle sclerotization. We propose a mechanistic model for tracheal filling. However, because the composition of the liquid is unknown, it remains hypothetical.

Hyperthermic overdrive: oxygen delivery does not limit thermal tolerance in Drosophila melanogaster.

The causes of thermal tolerance limits in animals are controversial. In many aquatic species, it is thought that the inability to deliver sufficient oxygen at high temperatures is more critical than impairment of molecular functions of the mitochondria. However, terrestrial insects utilize a tracheal system, and the concept of a mismatch between metabolic demand and circulatory performance might not apply to them. Using thermo-limit respirometry, it has been shown earlier in Drosophila melanogaster that CO(2) release rates at temperatures above the upper thermal limit (CT(max)) exceed the rate at CT(max). The nature of this post-CT(max), or "post-mortal" peak, is unknown. Either its source is increased aerobic mitochondrial respiration (hyperthermic overdrive), or an anaerobic process such as liberation of stored CO(2) from the hemolymph. The post-mortal peak of CO(2) release was found to be oxygen dependent. As the rate of CO(2) emission is a conservative indicator of rate of O(2) consumption, aerobic flux at the thermal limit is submaximal, which contradicts the theory that oxygen availability limits metabolic activity at high temperatures in insects. Consequently, the tracheal system should be capable of delivering sufficient oxygen for aerobic activity of the mitochondria at and above Ct(max).

Issues of convection in insect respiration: insights from synchrotron X-ray imaging and beyond.

While it has long been known that in small animals, such as insects, sufficient gas transport could be provided by diffusion, it is now recognized that animals generate and control convective flows to improve oxygen delivery across a range of body sizes and taxa. However, size-based methodological limitations have constrained our understanding of the mechanisms that underlie the production of these convective flows. Recently, new techniques have enabled the elucidation of the anatomical structures and physiological processes that contribute to creating and maintaining bulk flow in small animals. In particular, synchrotron X-ray imaging provides unprecedented spatial and temporal resolution of internal functional morphology and is changing the way we understand gas exchange in insects. This symposium highlights recent efforts towards understanding the relationship between form, function, and control in the insect respiratory system.

Spiracle activity in moth pupae--the role of oxygen and carbon dioxide revisited.

After decades of intensive research, the actual mechanism behind discontinuous gas exchange in insects has not been fully understood. One open question concerns the actual way (closed, flutter, and open) of how spiracles respond to tracheal gas concentrations. As the results of a classic paper [Burkett, B.N., Schneiderman, H.A., 1974. Roles of oxygen and carbon dioxide in the control of spiracular function in cecropia pupae. Biological Bulletin 147, 274-293] allow ambiguous interpretation, we thus reexamined the behavior of the spiracles in response to fixed, controlled endotracheal gas concentrations. The tracheal system of diapausing pupae of Attacus atlas (Saturniidae, Lepidoptera) was flushed with gas mixtures varying in P(O(2)) and P(CO(2)) while the behavior of the spiracles was monitored using changes in the pressure signal. This novel pressure based technique proved to be superior to classic visual observation of single spiracles. A two-dimensional map of the spiracle behavior in response to endotracheal P(O(2)) and P(CO(2)) was established. Typically, it contained two distinct regions only, corresponding to "closed" and "open" spiracles. A separate "flutter" region was missing. Because fluttering is commonly observed in moth pupae, we suggest that the intermittent spiracle opening during a flutter phase is an effect of non-steady-state conditions within the tracheal system. For low P(CO(2)) the minimum P(O(2)) resulting in open spiracles was linearly dependent upon P(CO(2)). Above a threshold of 1-1.5 kPa CO(2) the spiracles were open irrespective of P(O(2)). We propose a hypothetical spiracular control model, which is simple and explains the time course of endotracheal partial pressures during all phases of discontinuous gas exchange.

Pump out the volume--The effect of tracheal and subelytral pressure pulses on convective gas exchange in a dung beetle, Circellium bacchus (Fabricus).

Many flightless beetles like the large apterous dung beetle Circellium bacchus, possess a subelytral cavity (SEC) providing an extra air space below the elytra which connects to the tracheal system (TS) via metathoracic and abdominal spiracles. By measuring subelytral and intratracheal pressure as well as body movements and gas exchange simultaneously in a flow-through setup, we investigated the contribution of convection on Circellium respiratory gas exchange. No constriction phase was observed. TS and SEC pressures were always around atmospheric values. During interburst phase open abdominal spiracles and a leaky SEC led to small CO(2)-peaks on a continuous CO(2) baseline, driven by intermittent positive tracheal pressure peaks in anti-phase with small negative subelytral pressure peaks caused by dorso-ventral tergite action. Spiracle opening was accompanied by two types of body movements. Higher frequency telescoping body movements at the beginning of opening resulted in high amplitude SEC and TS pressure peaks. High frequency tergite movements caused subelytral pressure peaks and led to a saw tooth like CO(2) release pattern in a burst. We propose that during the burst open mesothoracic spiracles increase the compliance of the subelytral cavity allowing big volumes of tracheal air being pulled out by convection.

The prognostic value of cytology and fluorescence in situ hybridization in the follow-up of nonmuscle-invasive bladder cancer after intravesical Bacillus Calmette-Guérin therapy.

Molecular markers reliably predicting failure or success of Bacillus Calmette-Guérin (BCG) in the treatment of nonmuscle-invasive urothelial bladder cancer (NMIBC) are lacking. The aim of our study was to evaluate the value of cytology and chromosomal aberrations detected by fluorescence in situ hybridization (FISH) in predicting failure to BCG therapy. Sixty-eight patients with NMIBC were prospectively recruited. Bladder washings collected before and after BCG instillation were analyzed by conventional cytology and by multitarget FISH assay (UroVysion, Abbott/Vysis, Des Plaines, IL) for aberrations of chromosomes 3, 7, 17 and 9p21. Persistent and recurrent bladder cancers were defined as positive events during follow-up. Twenty-six of 68 (38%) NMIBC failed to BCG. Both positive post-BCG cytology and positive post-BCG FISH were significantly associated with failure of BCG (hazard ratio (HR)= 5.1 and HR= 5.6, respectively; p < 0.001 each) when compared to those with negative results. In the subgroup of nondefinitive cytology (all except those with unequivocally positive cytology), FISH was superior to cytology as a marker of relapse (HR= 6.2 and 1.4, respectively). Cytology and FISH in post-BCG bladder washings are highly interrelated and a positive result predicts failure to BCG therapy in patients with NMIBC equally well. FISH is most useful in the diagnostically less certain cytology categories but does not provide additional information in clearly malignant cytology.

[Diagnosis and therapy of acute ureteral colic]. / Diagnostik und Therapie der Harnleitersteinkolik.

Acute ureteral colic presents with a complex of acute and characteristic flank pain that usually indicates the presence of a stone in the urinary tract. Diagnosis and management of renal colic have undergone considerable evolution and advancement in recent years. The application of noncontrast helical computed tomography (CT) in patients with suspected ureteral colic is one major advance in the primary diagnostic process. The superior sensitivity and specificity of helical CT allow ureterolithiasis to be diagnosed without the potential side effects of contrast media. Initial management is based on three key concepts: (A) rational and fast diagnostic process (B) effective pain control (C) and understanding of the impact of stone location and size on the natural course of the disease and definitive urologic management. These concepts are discussed in this review with reference to contemporary literature.

L-carnitine-L-tartrate promotes human hair growth in vitro.

The trimethylated amino acid l-carnitine plays a key role in the intramitochondrial transport of fatty acids for beta-oxidation and thus serves important functions in energy metabolism. Here, we have tested the hypothesis that l-carnitine, a frequently employed dietary supplement, may also stimulate hair growth by increasing energy supply to the massively proliferating and energy-consuming anagen hair matrix. Hair follicles (HFs) in the anagen VI stage of the hair cycle were cultured in the presence of 0.5-50 microm of l-carnitine-l-tartrate (CT) for 9 days. At day 9, HFs treated with 5 microm or 0.5 microm of CT showed a moderate, but significant stimulation of hair shaft elongation compared with vehicle-treated controls (P < 0.05). Also, CT prolonged the duration of anagen VI, down regulated apoptosis (as measured by TUNEL assay) and up regulated proliferation (as measured by Ki67 immunohistology) of hair matrix keratinocytes (P < 0.5). By immunohistology, intrafollicular immunoreactivity for TGFbeta2, a key catagen-promoting growth factor, in the dermal papilla and TGF-beta II receptor protein in the outer root sheath and dermal papilla was down regulated. As shown by caspase activity assay, caspase 3 and 7, which are known to initiate apoptosis, are down regulated at day 2 and day 4 after treatment of HFs with CT compared with vehicle-treated control indicating that CT has an immediate protective effect on HFs to undergo programmed cell death. Our findings suggest that l-carnitine stimulates human scalp hair growth by up regulation of proliferation and down regulation of apoptosis in follicular keratinocytes in vitro. They further encourage one to explore topical and nutraceutical administration of l-carnitine as a well-tolerated, relatively safe adjuvant treatment in the management of androgenetic alopecia and other forms of hair loss.

Retroperitoneoscopic nephrectomy for autosomal dominant polycystic kidney disease: initial experience.

INTRODUCTION: Nephrectomy for autosomal dominant polycystic kidney disease (ADPKD) has been reported to have significant morbidity and mortality. Because of the large kidney size, laparoscopic nephrectomy is technically demanding and there have been only few reports on this subject. We describe our retroperitoneoscopic technique and review the literature. METHODS: Retroperitoneoscopic nephrectomy was performed in 2 patients. A four-port retroperitoneal access was used, after hilar control the kidney was freed and extracted. RESULTS: The mean operative time was 155 min, the mean intraoperative blood loss was 125 ml. There were no intraoperative complications. A postoperative retroperitoneal hematoma in 1 of the patients was managed conservatively with transfusion. CONCLUSION: Retroperitoneoscopic nephrectomy for ADPKD is feasible. The main advantages of this technique compared to transperitoneal laparoscopy are the quick and easy access to the hilar vessels even in large polycystic kidneys and the strict extraperitoneal route.

Short-, intermediate-, and long-term quality of life after laparoscopic radical prostatectomy--does the learning curve of LRP have a negative impact on patients' quality of life?

OBJECTIVES: To evaluate quality of life (QoL) after laparoscopic radical prostatectomy (LRP) and investigate whether the learning curve of laparoscopic novices has a negative influence on patients' QoL. METHODS: Evaluation of QoL with the EORTC QLQ C-30 and the PR25 preoperatively (t0) as well as postoperatively after 1-3 mo (t1), 4-6 mo (t2), 7-12 mo (t3), 13-24 mo (t4), and yearly thereafter (t5-t7). Surgeons were grouped according to their prior experience in laparoscopy into experienced and novices. RESULTS: LRP was performed in 343 patients; 268 (78%) participated in the study. The mean patient age was 63.3+/-6.3 yr; mean PSA, 10.0+/-9.2 ng/ml; mean follow-up, 26 mo. Global health was impaired for t1 (p<0.001) and then returned to baseline. Emotional functioning improved (p<0.001) for t2-t7 versus baseline. Physical functioning remained impaired for t1-t2, and role and social functioning for t1-t6. Only sexual functioning did not return to baseline for t1-t7. Urinary symptoms were worse at t1 and then improved gradually (p<0.001). No significant difference in any QoL domain could be identified for experienced surgeons versus novices except for financial difficulties at t2-t3, which related to social differences. Thirty-one (9%) patients with adjuvant therapy had significantly worse global health, bowel symptoms, urinary symptoms, fatigue, and sexual functioning. CONCLUSIONS: The learning curve of laparoscopic novices does not have a negative impact on patients' QoL. For intermediate- to long-term follow-up, patients reach their baseline or score even better in all domains except for sexual functioning but are significantly impaired if adjuvant treatment is performed.

Intermediate-term results of retroperitoneoscopy-assisted cryotherapy for small renal tumours using multiple ultrathin cryoprobes.

OBJECTIVES: To evaluate outcome after retroperitoneoscopic cryotherapy for small renal tumours. METHODS: Fourteen patients underwent cryoablation performed with six ultrathin 1.5-mm cryoprobes. Retroperitoneoscopic access was used for any tumour location. A double freeze-thaw cycle was performed under simultaneous retroperitoneoscopic visual control and real-time ultrasound monitoring. RESULTS: Mean tumour size was 2.8 cm (range: 2.0-4.0), mean patient age was 68 yr (range: 49-83), and six left and eight right kidneys were treated. The mean operative time was 167 min (range: 120-200); mean blood loss was 93 ml (range: 0-300). Cryosurgery was successfully performed in all 14 patients, with 13 patients undergoing assisted retroperitoneoscopy and one patient, after previous open nephropexy, undergoing an open approach. Intraoperative biopsy specimens revealed renal cell cancer (RCC) in 10 (71%) patients. The only intraoperative complication was bleeding after removal of the cryoprobes in four (29%) patients, necessitating one intracorporeal stitch in each. Two (14%) of the first four patients presented postoperatively with superficial skin frostbite, which healed with conservative treatment. During mean follow-up of 21 mo (range: 2-42), 2 (14%) patients died from unrelated disease, and 12 patients remained without evidence of local recurrence. One patient with previous contralateral nephrectomy for RCC developed retroperitoneal lymph node metastasis on that side without recurrence in the cryoablated kidney. CONCLUSIONS: Retroperitoneoscopic cryotherapy using multiple ultrathin cryoprobes is safe and effective with encouraging oncologic results on intermediate-term follow-up. Prospective clinical trials and long-term oncologic data are needed to define its definitive role in treatment of renal tumours.

Safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing oral anticoagulation.

OBJECTIVES: Ongoing oral anticoagulation (OA) contraindicates transurethral electroresection of the prostate. We evaluated the safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing OA with coumarin derivatives, aspirin, or clopidogrel, complaining of symptomatic benign prostatic hyperplasia (BPH). METHODS: We evaluated perioperative parameters, functional outcome, and adverse events up to 24 mo postoperatively of patients on OA, and compared results with 92 men at normal risk without anticoagulant therapy undergoing PVP for the same indication (control). RESULTS: Within 40 mo, 116 men on OA were included, with 31% (n=36) receiving coumarin derivatives; 61% (n=71), aspirin; and 8% (n=9), clopidogrel. Mean prostate volume (62+/-34ml vs. 57+/-25ml; p=0.289) and mean operation time (67+/-28min vs 63+/-29min; p=0.313) were comparable with control. We observed no bleeding complications necessitating blood transfusions. Average postoperative decrease of haemoglobin was 8.6% for patients on OA versus 8.8% for control. At 3, 6, 12, and 24 mo postoperatively, improvement of the International Prostate Symptom Score ranged from 60-70%; postvoid residual volume, 80-88%; and average maximum urinary flow rate, 116-140%, respectively. Postoperative complications were low and comparable with control. CONCLUSIONS: PVP is characterized by excellent haemostatic properties and very low intraoperative complication rate even in patients on OA. On the basis of our perioperative results, we recommend PVP as first-line procedure for patients with symptomatic BPH at high risk of bleeding.

Laparoscopic extended pelvic lymph node dissection for high-risk prostate cancer.

INTRODUCTION: Recently, some controversy has arisen as to whether pelvic lymphadenectomy is still necessary for patients with prostate cancer who are undergoing radical prostatectomy. We prospectively evaluated the results and morbidity of laparoscopic extended pelvic lymph node dissection in patients with high-risk prostate cancer defined as a serum prostate-specific antigen (PSA) level greater than 10 ng/mL or preoperative biopsy Gleason score of 7 or more. TECHNICAL CONSIDERATIONS: In 123 consecutive patients with clinically organ-confined high-risk prostate cancer, laparoscopic extended pelvic lymphadenectomy was performed before laparoscopic radical prostatectomy. The boundaries of the pelvic lymph node dissection were the bifurcation of the common iliac artery superiorly, the node of Cloquet inferiorly, the external iliac vein laterally, and the bladder wall medially. Preparation was done with bipolar forceps and scissors, with meticulous coagulation of all lymphatic tissue. The mean PSA level was 14.8 ng/mL (range 1.5 to 43.4). The mean number of lymph nodes removed was 21 (range 9 to 55). A total of 21 patients (17%) had lymph node metastases. The overall complication rate was 4%. CONCLUSIONS: Laparoscopic extended pelvic lymph node dissection is safe and effective. The results and morbidity are equivalent to those of open surgery, with the advantage of a minimally invasive operative technique.