Transvesical Suprapubic Externalization of Ureteral Stents - Introduction of a Surgical Innovation at the Development Stage.

BACKGROUND AND OBJECTIVES: In this study, we describe our first experiences with the new method of transvesical suprapubic externalization of ureteral stents. This method is assessed in patients with incurable ureteral obstruction and concomitant bladder dysfunction, and is classified according to the Idea, Development, Exploration, Assessment, Long-Term Study (IDEAL) recommendations. PATIENTS AND METHODS: From 2009 to 2015, transvesical suprapubic externalization of ureteral stents was applied in 14 (8 males, 6 females) patients with incurable ureteral obstruction of malignant (n = 9, 64%) or benign (n = 5; 36%) etiology. All the patients had concomitant bladder pathologies that impaired quality of life (QoL). Classification according to IDEAL followed the respective recommendations. RESULTS: Only minor complications, except 1 major complication not directly related to the procedure, were observed. QoL improvement was reported in all patients. The duration for this surgery was 45 (17-86) min; however, it varied between genders (female 37 min, male 51 min). The mean follow-up period was 26.6 months ranging from 12 to 73 months. Transvesical suprapubic externalization of ureteral stents resulted in a stable renal function and the elimination of urinary leakage via a compromised bladder in all patients. CONCLUSIONS: Transvesical externalization of ureteral stents is a feasible method for urinary diversion, which seems to improve patients' QoL in appropriate indications. The method can be classified as IDEAL stage 2a.

Protocol for a Randomized Phase II Trial for Mesh Optimization by Autologous Plasma Coating in Prolapse Repair: IDEAL Stage 3.

INTRODUCTION: Mesh-related complications especially after vaginal implantation have raised awareness lately because of severe adverse reactions and legal aspects. About 20% of patients suffer from complications after mesh insertion in the anterior vaginal wall. Autologous plasma coating of meshes prior to implantation has shown potential to improve the biocompatibility of meshes in vivo and in vitro. This innovative approach has been developed according to the IDEAL recommendations for surgical innovations. The method has still to be assessed at stage 3 accordingly. METHODS: A protocol is developed for a prospective single-blinded randomized controlled phase II trial for biocompatibility optimization of anterior vaginal meshes for prolapse repair by autologous plasma coating versus non-coated meshes. RESULTS: The protocol aims at fulfilling the requirements for stage 3 (assessment) according to IDEAL. Eligible for inclusion are women with primary cystocele, requiring a surgical procedure, suitable for randomization, and willing to be randomized. Participants will be followed up by postal questionnaires (6 months post surgery and 12 months post randomization) and will also be reviewed in clinic 12 and 24 months post surgery. Primary endpoint is the assessment of mesh-related complications following the Clavien-Dindo classifications. QoL, sexual function assessment, efficacy, and validation of an already developed long-term register are considered secondary endpoints. To afford a calculated 10% reduction of postoperative complications through plasma-coated meshes vs. non-coated meshes at 1-year follow-up, a total 214 women in each arm will be necessary to achieve 80% power at a significance level of 5%. CONCLUSION: The protocol for this randomized clinical trial represents the conditions to assess the surgical innovation of plasma coating of meshes in order to improve the meshes' biocompatibility at stage 3 according to the IDEAL recommendations.

Coating of mesh grafts for prolapse and urinary incontinence repair with autologous plasma: exploration stage of a surgical innovation.

PURPOSE: Optimized biocompatibility is a major requirement for alloplastic materials currently applied for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) repair. In the preliminary studies the mesh modification by coating with autologous plasma resulted in the increased adherence score in vitro and improved biocompatibility in an animal model. The first use of plasma coated meshes in human is presented. MATERIALS AND METHODS: Between 04/2013 and 05/2014, 20 patients with the indication for SUI and POP repair were selected in a single institution. The applied meshes were modified by autologous plasma coating prior to implantation. A retrospective chart review for peri- and early postoperative complications was performed. Functional outcome and QoL were evaluated pre- and postoperatively. RESULTS: The functional outcome and QoL improved significantly in all groups. Two reoperations (Grade IIIB) with the release of TVT-mesh in anesthesia due to the obstruction were needed. No other severe complications were registered. CONCLUSION: For the first time we applied a mesh modification in a human setting according to IDEAL criteria of surgical innovations. The procedure of mesh coating with autologous plasma is safe and a prospective randomized trial proving a positive effect of plasma coating on the biocompatibility and morbidity outcome with long-term registry is planned.

Metastatic penile carcinoma - an update on the current diagnosis and treatment options.

INTRODUCTION: Penile carcinoma has an incidence of 4,000 cases in Europe. The therapy and prognosis depend decisively on the lymph node status. Lymph node metastases are detected in 23-65% cases depending on the histopathological pattern. Due to improved diagnostic methods an early detection of tumor stage is possible. Multimodal therapeutic concepts can offer curability for a subset of patients, even those suffering from advanced disease. MATERIAL AND METHODS: Current data on penile cancer based on a selective review of the literature by PubMed and the EAU guidelines 2009. RESULTS: Invasive diagnostic tools, such as fine-needle biopsy (FNB) and dynamic sentinel node biopsy (DSNB), improved the diagnosis of lymph node status considerably and reduced the morbidity in specialized centers. The application of 18F-FDG-PET/CT for metastases detection needs further evaluation due to inconsistent results. Inguinal lymphadenectomy is the therapeutic standard in case of metastases proof. It was possible to reduce the complications due to the new modified operation techniques. Patients with extended lymph node and distant metastases have a poor prognosis. Different systemic polychemotherapy regimes are applied currently and are associated with poor outcome (response rates <50%) and high morbidity. Neoadjuvant chemotherapy is recommended in patients with unresectable and relapsing lymph node metastases. CONCLUSIONS: Currently, inconsistent therapy regimens are applied for metastatic penile cancer. Standardization is urgently needed through the development of high-quality studies and long-term registers in order to lower the morbidity and increase the efficiency of diagnosis and therapy.

Inflammatory reaction as determinant of foreign body reaction is an early and susceptible event after mesh implantation.

PURPOSE: To investigate and relate the ultrashort-term and long-term courses of determinants for foreign body reaction as biocompatibility predictors for meshes in an animal model. MATERIALS AND METHODS: Three different meshes (TVT, UltraPro, and PVDF) were implanted in sheep. Native and plasma coated meshes were placed bilaterally: (a) interaperitoneally, (b) as fascia onlay, and (c) as muscle onlay (fascia sublay). At 5 min, 20 min, 60 min, and 120 min meshes were explanted and histochemically investigated for inflammatory infiltrate, macrophage infiltration, vessel formation, myofibroblast invasion, and connective tissue accumulation. The results were related to long-term values over 24 months. RESULTS: Macrophage invasion reached highest extents with up to 60% in short-term and decreased within 24 months to about 30%. Inflammatory infiltrate increased within the first 2 hours, the reached levels and the different extents and ranking among the investigated meshes remained stable during long-term follow up. For myofibroblasts, connective tissue, and CD31+ cells, no activity was detected during the first 120 min. CONCLUSION: The local inflammatory reaction is an early and susceptible event after mesh implantation. It cannot be influenced by prior plasma coating and does not depend on the localisation of implantation.

Coating with autologous plasma improves biocompatibility of mesh grafts in vitro: development stage of a surgical innovation.

PURPOSE: To investigate mesh coating modalities with autologous blood components in a recently developed in vitro test system for biocompatibility assessment of alloplastic materials. MATERIALS AND METHODS: Seven different mesh types, currently used in various indications, were randomly investigated. Meshes were coated prior to cultivation with autologous peripheral blood mononuclear cells (PBMCs), platelets, and blood plasma. Pretreated meshes were incubated over 6 weeks in a minced tissue assay, representative for fibroblasts, muscle cells, and endothelial cells originating from 10 different patients. Adherence of those tissues on the meshes was microscopically investigated and semiquantitatively assessed using a previously described scoring system. RESULTS: Coating with peripheral blood mononuclear cells did not affect the adherence score, whereas coating with platelets and blood plasma increased the score suggesting improved biocompatibility in vitro. The previous ranking of native meshes remained consistent after coating. CONCLUSION: Plasma coating of meshes improves their biocompatibility score in a novel in vitro test system.

Combined treatment with pazopanib and vinflunine in patients with advanced urothelial carcinoma refractory after first-line therapy.

The role of pazopanib in the second-line setting of refractory metastatic transitional cell carcinoma of the urothelium has not been defined clearly. The aim of this phase I/II trial was to assess the safety, tolerability, and efficacy of combining pazopanib and vinflunine in patients with metastatic transitional cell carcinoma of the urothelium after failure of first-line platinum-containing therapy. From May 2011 to December 2011, five patients were enrolled in this trial. Pazopanib was the investigated compound; four levels were planned (200, 400, 600, and 800 mg/day). Vinflunine was dosed at 280 mg/m for the first dose and 320 mg/m every 3 weeks thereafter. After the definition of a tolerated dose for the combined therapy, a subsequent phase II study was planned. At the starting level, pazopanib 200 mg/day, dose-limiting toxicities were observed in two of five patients. One patient experienced grade 4 febrile neutropenia, which led to treatment discontinuation. A second patient showed grade 3 hepatobiliary disorder with an increase in γ-glutamyltransferase. The study was interrupted at dose level 1 for safety reasons. The initially planned phase II study was therefore not carried out. This phase I study showed that combined therapy of daily pazopanib (200 mg) and vinflunine (280/320 mg/m) every 3 weeks is poorly tolerated in patients with refractory advanced urothelial cancer.

Early endoscopic detection and subsequent removal of sphincter penetrating anastomotic sutures may prevent irreversible urinary incontinence after radical prostatectomy.

BACKGROUND AND PURPOSE: Iatrogenic sphincter lesions are possible reasons for sphincteric incompetence and postprostatectomy urinary incontinence. The aim of this study was to identify early possible sphincter injuries as causes for urinary incontinence after radical prostatectomy by endoscopic evaluation of the anastomotic region. PATIENTS AND METHODS: Among 374 patients who had undergone radical prostatectomy from 2005 to 2009 at our institution, we investigated patients with early postoperative urinary incontinence. Nineteen incontinent patients were identified with the symptomatic triad of early incontinence, reduced urinary flow, and post-void residual (PVR) volume after catheter removal. Patients were examined endoscopically, and the clinical effect of early suture removal in patients with sphincter penetration was evaluated. RESULTS: Urethrocystoscopic evaluation revealed an isolated sphincter penetration as reason for early postoperative incontinence in 15/19 cases. The suture penetration was observed predominantly in the 3-degree (7/19) and 9-degree (8/19) positions and less frequently in the 12-degree (2/19) and 6-degree (2/19) positions. Four of (21%) 19 patients did show an additional sphincter transection. The penetrating sutures of the urethrovesical anastomosis were removed during the endoscopic procedure, and initial urinary incontinence could be corrected in all cases of isolated sphincter penetration. CONCLUSION: Early severe urinary incontinence, reduced urinary flow, and PVR volume after radical prostatectomy may indicate sphincter penetration by anastomosis sutures. In our patients, early transurethral punctual removal of the penetrating sutures could decrease the early postoperative incontinence rate.

Evaluation of Biocompatibility of Alloplastic Materials: Development of a Tissue Culture In Vitro Test System.

Optimized biocompatibility is a major requirement for alloplastic materials currently applied in surgical approaches for hernia, incontinence, and prolapse situations. Tissue ingrowth/adherence and formation of connective tissue seem to have important influence in mesh incorporation at the implant site. In an in vitro approach we randomly investigated 7 different mesh types currently used in surgeries with various indications with regard to their adherence performance. Using a tissue culture approach, meshes were incubated with tissue representative of fibroblasts, muscle cells, and endothelial cells originating from 10 different patients. After 6 weeks, the meshes were assessed microscopically and a ranking of their adherence performance was established. Tissue culture was successful in 100% of the probes. We did not remark on interindividual differences concerning the growth and adherence performance after incubation with the different meshes in the investigated 10 patients. The ranking was consistent in all patients. In this test system, PVDF Dynamesh® (FEG Textiltechnik, Aachen, Germany) was the mesh with the best growth-in score. The test system was feasible and reproducible. Pore size seems to be a predictor of adherence performance. The test system may be a helpful tool for further investigations, and the predictive value should be assessed in further in vitro and in vivo experiments.