Comparative analysis of Bricker versus Wallace ureteroenteric anastomosis and identification of predictors for postoperative ureteroenteric stricture.

PURPOSE: Ureteroenteric anastomosis after cystectomy is usually performed using the Bricker or Wallace technique. Deterioration of renal function is the most common long-term complication of urinary diversion (UD). To improve surgical care and optimize long-term renal function, we compared the Bricker and Wallace anastomotic techniques and identified risk factors for ureteroenteric strictures (UES) in patients after cystectomy. MATERIAL AND METHODS: Retrospective, monocentric analysis of 135 patients who underwent cystectomy with urinary diversion at the University Hospital Essen between January 2015 and June 2019. Pre- and postoperative renal function, relevant comorbidities, prior chemo- or radiotherapy, pathological findings, urinary diversion, postoperative complications, and ureteroenteric strictures (UES) were analyzed. RESULTS: Of all 135 patients, 69 (51.1%) underwent Bricker anastomosis and 66 (48.9%) Wallace anastomosis. Bricker and Wallace groups included 134 and 132 renal units, respectively. At a median follow-up of 14 (6-58) months, 21 (15.5%) patients and 30 (11.27%) renal units developed UES. We observed 22 (16.6%) affected renal units in Wallace versus 8 (5.9%) in Bricker group (p < 0.001). A bilateral stricture was most common in Wallace group (69.2%) (p < 0.001). Previous chemotherapy and 90-day Clavien-Dindo grade ≥ III complications were independently associated with stricture formation, respectively (OR 9.74, 95% CI 2-46.2, p = 0.004; OR 4.01, 95% CI 1.36-11.82, p = 0.013). CONCLUSION: The results of this study show no significant difference in ureteroenteric anastomotic techniques with respect to UES development regarding individual patients but suggest a higher risk of bilateral UES formation in patients undergoing Wallace anastomosis. This is reflected in the increased UES rate under consideration of the individual renal units.

Transrectal Ultrasound Guided Hydrodistension - A New Surgical Way in Transgender Surgery.

BACKGROUND: Creating the neovaginal canal in transwomen is one of the most delicate steps of Genital Gender Affirming Surgery (GGAS). Injury to the rectum is a rare but serious complication that can lead to further surgery and even creation of a colostomy. AIM: Implementation of a novel hydrospacing technique (HST) based on transrectal ultrasound (TRUS)-guided hydrodistension. METHODS: Between June 2018 and June 2020 54 transwomen received GGAS with HST. Immediately before GGAS transperineal hydrodistension was performed using a TSK-Supra-Needle (20 Gauge, 120 mm length), that was placed under direct TRUS-guided visual control between Denonvilliers' fascia and the anterior rectal wall. 40 - 60 ml normal saline were administered perineally to separate Denonvilliers' fascia from the anterior rectal wall to create a dissection of at least 20 mm. For better intraoperative visualization the hydrodissected space was also dyed using 2ml of methylenblue while retracting the needle. A retrospectively analysed, clinically and demographically comparable series of 84 transwomen who underwent GGAS between June 2016 and June 2018 served as control group. All 138 surgeries were performed by the same experienced surgeon. OUTCOMES: The effect of the novel hydrospacing technique on neovaginal dimensions and operating time. RESULTS: Patients in both groups did not differ in baseline patient characteristics such as age and body mass index (HST 35 vs 38 years in control group, P = .44 and body mass index 26 vs 25 kg/m2, P = .73). Vaginal depth and width were significantly larger in the HST subgroup as compared to controls (14.4 cm vs 13.5 cm, P = .01 and 4.2 cm vs 3.8 cm, P < .001). No statistically significant difference occurred in intraoperative rectal injury (n = 0 in HST group, n = 2 in control group, P = .26). Median total OR-time was comparable for GGAS including HST before vaginoplasty to standard technique (211 minutes for HST vs 218 minutes; P = 0.19). CLINICAL IMPLICATIONS: The proposed additional surgical step during GGAS is minimally invasive and safe, simplifies GGAS and potentially helps to avoid complications such as rectal injury. STRENGTH & LIMITATIONS: Single-surgeon series, limited follow-up time and no prospective randomization. CONCLUSION: HST is a safe and feasible procedure, which facilitates a safe preparation of the neovaginal canal during male to female GGAS. Panic A, Rahmani N, Kaspar C, et al. Transrectal Ultrasound Guided Hydrodistension - A New Surgical Way in Transgender Surgery. J Sex Med 2021;18:1135-1141.

The value of an additional scrotal suture during orchidopexy.

INTRODUCTION: Undescended testes present in 3-5% of male infants at birth. Orchidopexy is indicated to improve fertility and reduce the risk of testicular tumors. Guidelines recommend orchidopexy as early as six months of age, treatment should be finished within the age of 18 months. So far, no unequivocal proof demonstrated the superiority of one of the different surgical techniques. OBJECTIVE: To evaluate the value of an additional scrotal suture between the tunica albuginea and the dartos fascia during orchidopexy in an outpatient setting. It is yet unclear, whether the suture influences the incidence of secondary cryptorchidism or recurrence. STUDY DESIGN: This is a retrospective cohort study. Between 2010 and 2018 two experienced surgeons performed 561 inguinal orchidopexy-procedures in an open technique (375 boys). In group 1 (2010-2014) they managed 234 IOP (156 boys) without an additional scrotal suture. Since 2014, in group 2 an additional suture has been performed in 327 IOP (219 boys). Statistically, we compared both groups over a period of consecutive 4 years after the model of a life table analysis (Logrank). RESULTS: The numbers of boys with complete follow-up were 118 of 156 in group 1 and 154 of 219 in group 2, demonstrating 7 (5.9%) and 7 (4.5%) recurrences, respectively. There was no statistically significant difference in recurrences between group 1 and group 2 (Logrank-Test, p = 0.97). Orchidopexie failure was detected between 0.9 and 23.1 months after the IOP in group 1 and between 3.2 and 17.7 months in group 2. Mean age in months at the operation in both groups was significantly higher than the recommended 6-18 months in the EAU/AUA-guidelines. Both groups showed similar rates of postoperative complications. DISCUSSION: Orchidopexy is a safe procedure in an outpatient setting. So far there is no evidence that performing an additional scrotal suture decreases the operative failure rate in inguinal standard orchidopexy procedures.

Renal duplication with ureter duplex not following Meyer-Weigert-Rule with development of a megaureter of the lower ureteral segment due to distal stenosis - A case report.

Meyer-Weigert-Rule predicts the draining pattern of duplex ureters in bipolar renal duplications. The upper pole is normally seen as ectopic and therefore dysplastic due to obstruction, whereas the lower pole is related to vesicoureteral reflux. In our case, this rule is violated with uncrossed ureter duplex and a dysplastic lower pole in connection with obstruction.

17ß-estradiol inhibits hepatic iNOS via the activation of the estrogen receptor ER-α and inhibition of erk1/2-mir-221 axis.

17ß-Estradiol (E2) is known to negatively regulate inducible nitric oxide (NO) synthase (iNOS) expression via estrogen receptor alpha (ER-α) activation in aortic vascular smooth muscle cells.Therefore, we sought to determine whether E2 can inhibit iNOS in vivo in hepatic tissue via the activation of ER-α and whether extracellular signal-regulated kinases 1/2 (ERK1/2)-miR-221 axis is involved in this process. Male Wistar rats were treated with a bolus injection of E2 intraperitoneally (40 µg/kg), and 24 hours after treatment the animals were sacrificed and the livers excised. The protein levels of iNOS, p50 and p65 subunits of nuclear factor κB (NFκB), ERα, ERK1/2 and protein kinase B (Akt), as well as the association of ERα/Src in liver lysates were assessed by Western blot. The expression of hepatic miR-221 was analyzed by qRT-PCR. Results show that E2 reduced hepatic iNOS protein expression (p less than 0.01), the protein level of ERα (p less than 0.05), ERK1/2 (p less than 0.05), Akt phosphorylation (p less than 0.001) and miR-221 expression (p less than 0.05). In contrast, hepatic ERα/Src kinase association level (p less than 0.05) increased after E2 treatment. Our results indicate that E2 inhibits hepatic iNOS via molecular mechanisms involving the activation of the ER-α and inhibition of ERK1/2-miR-221 axis.

Sexuality after Male-to-Female Gender Affirmation Surgery.

Male-to-Female (MtF) gender affirmation surgery (GAS) comprises the creation of a functional and aesthetic perineogenital complex. This study aimed to evaluate the effect of GAS on sexuality. We retrospectively surveyed all 254 MtF transsexual patients who had undergone GAS with penile inversion vaginoplasty at the Department of Urology, University Hospital Essen, Germany, between 2004 and 2010. In total, we received 119 completed questionnaires after a median of 5.05 years since surgery. Of the study participants, 33.7% reported a heterosexual, 37.6% a lesbian, and 22.8% a bisexual orientation related to the self-perceived gender. Of those who had sexual intercourse, 55.8% rated their orgasms to be more intensive than before, with 20.8% who felt no difference. Most patients were satisfied with the sensitivity of the neoclitoris (73.9%) and with the depth of the neovaginal canal (67.1%). The self-estimated pleasure of sexual activity correlated significantly with neoclitoral sensitivity but not with neovaginal depth. There was a significant correlation between the ease with which patients were able to become sexually aroused and their ability to achieve orgasms. In conclusion, orgasms after surgery were experienced more intensely than before in the majority of women in our cohort and neoclitoral sensitivity seems to contribute to enjoyment of sexual activity to a greater extent than neovaginal depth.

AQP1, AQP5, Bcl-2 and p16 in pharyngeal squamous cell carcinoma.

OBJECTIVE: This study aimed to link expression patterns of AQP1, AQP5, Bcl-2 and p16 to clinicopathological characteristics of oro-hypopharyngeal squamous cell carcinomas. METHODS: Immunohistochemical expression of AQP1, AQP5, Bcl-2 and p16 was investigated in 107 consecutive oro-hypopharyngeal squamous cell carcinoma cases. Molecular interrelationship and correlations with clinicopathological parameters and survival were computed. RESULTS: AQP1 was expressed exclusively by a subgroup of basaloid-like squamous cell carcinomas. AQP5 was detected in 25.2 per cent of the samples, showing significant association with the absence of p16 and Bcl-2 (p = 0.018; p = 0.010). In multivariate analysis, overexpression of p16 was significantly correlated with favourable overall survival (p = 0.014). CONCLUSION: AQP5 defined a subset of patients with Bcl-2-negative and p16-negative tumours with a poor clinical outcome. AQP1 was found to be a marker of a subgroup of aggressive basaloid-like squamous cell carcinomas. These findings suggest that AQP1 and AQP5 are interesting candidates for further studies on risk group classification and personalised treatment of oro-hypopharyngeal squamous cell carcinomas.

Endothelial Caveolin-1 regulates the radiation response of epithelial prostate tumors.

The membrane protein caveolin-1 (Cav1) recently emerged as a novel oncogene involved in prostate cancer progression with opposed regulation in epithelial tumor cells and the tumor stroma. Here we examined the role of stromal Cav1 for growth and radiation response of MPR31-4 prostate cancer xenograft tumors using Cav1-deficient C57Bl/6 mice. Syngeneic MPR31-4 tumors grew faster when implanted into Cav1-deficient mice. Increased tumor growth on Cav1-deficient mice was linked to decreased integration of smooth muscle cells into the wall of newly formed blood vessels and thus with a less stabilized vessel phenotype compared with tumors from Cav1 wild-type animals. However, tumor growth delay of MPR31-4 tumors grown on Cav1 knockout mice to a single high-dose irradiation with 20 Gray was more pronounced compared with tumors grown on wild-type mice. Increased radiation-induced tumor growth delay in Cav1-deficient mice was associated with an increased endothelial cell apoptosis. In vitro studies using cultured endothelial cells (ECs) confirmed that the loss of Cav1 expression increases sensitivity of ECs to radiation-induced apoptosis and reduces their clonogenic survival after irradiation. Immunohistochemical analysis of human tissue specimen further revealed that although Cav1 expression is mostly reduced in the tumor stroma of advanced and metastatic prostate cancer, the vascular compartment still expresses high levels of Cav1. In conclusion, the radiation response of MPR31-4 prostate tumors is critically regulated by Cav1 expression in the tumor vasculature. Thus, Cav1 might be a promising therapeutic target for combinatorial therapies to counteract radiation resistance of prostate cancer at the level of the tumor vasculature.

[How should urologists perform implantation of subcutaneous central venous port systems? A single center experience of 347 cases]. / Wie sollen Urologen venöse subkutane Portsysteme implantieren? : Erfahrungen an einem Zentrum bei 347 Patienten.

BACKGROUND: Since 1999 urologists at the University of Essen in Germany have performed subcutaneous implantation of venous port systems, controlled by intravasal ECG. METHODS: Between December 1999 and June 2011 implantation of venous port systems was performed in 241 male (69.5%) and 106 (30.5%) female patients. The port systems were implanted subcutaneously above the pectoralis major muscle under local anesthesia. If it was not possible to isolate the cephalic vein or safe catheter implantation was not feasible, puncture of the subclavian vein was performed. RESULTS: The median follow-up was 491.6 days (2-2568), and 163.254 catheter days (mean 239 days, range 2-2604) were documented. During the follow-up period 191 (55.1%) patients died. The mean surgical implantation and explantation time was 36.5 min (14-85 min) and 25.4 min (10-46 min), respectively; 79.7% were implanted and controlled by ECG. Altogether, 390 devices were used in 379 surgical procedures, 355 implantations (91.1%) and 35 explantations (8.9%). Implanted vessels were the cephalic vein in 303 patients (85.6%) and the subclavian vein in 51 (14.4%) patients. Of 35 explanted devices, the explantation was necessary due to complications in 28 (8.0%) cases: infection n=6 (1.7%, 0.036 per 1,000 catheter days), occlusion n=8 (2.3%, 0.049 per 1,000 catheter days), dislocation n=7 (2.0%, 0.042 per 1,000 catheter days), deep vein thrombosis of the upper extremity n=6 (1.7%, 0.037 per 1,000 catheter days), and clotting n=1(0.3%, 0.006 per 1,000 catheter days). Premature catheter removal (<30 days post-op) was required in six cases (1.9%, 0.036 per 1,000 catheter days) due to complications: three catheter dislocations/malfunctions (0.9%, 0.019 per 1,000 catheter days), one port-related infection, one pocket port infection, and one deep vein thrombosis of the upper extremity (0.3%, 0.006 per 1,000 catheter days). Other problems described in the literature like pneumothorax, vein perforation, or pinch-off syndrome did not occur. CONCLUSIONS: Implantation of port systems with ECG control of the catheter tip position is related to a few cases of adverse events and good surgical outcomes. Furthermore, it has also shown great advantages in offering immediate support and early therapy initiation with a fast learning curve for the training urologists. The results of the presented analysis are comparable to those of surgical or radiological departments reported in the literature and provide good evidence that this procedure should be extended to urological centers with a high volume of chemotherapy patients.