A new concept for early recovery after surgery for patients undergoing radical cystectomy for bladder cancer: results of a prospective randomized study.

PURPOSE: Early recovery after surgery concepts have gained wide acceptance in various surgical specialties. However, limited data are available for radical cystectomy. A new early recovery after surgery concept was compared to a more conservative regimen in patients undergoing radical cystectomy for bladder cancer. MATERIALS AND METHODS: A total of 101 consecutive patients were prospectively randomized to early recovery after surgery (62) or a conservative regimen (39) (intended randomization ratio was 2 early recovery after surgery-to-1 conservative regimen). Primary end points were differences in quality of life, and secondary end points included postoperative morbidity, demand for analgesics, time spent in the intermediate care unit, mobility and number of gastrointestinal events during hospital stay. RESULTS: Quality of life parameters, as measured by the EORTC (European Organization for the Research and Treatment of Cancer) Quality of Life questionnaire QLQ-30 did not change significantly between postoperative days 3 and 7 and at discharge from hospital in the conservative regimen group, whereas a significant improvement was observed in the early recovery after surgery group. Postoperative morbidity was lower in the early recovery after surgery group in terms of wound healing disorders (p = 0.006), fever (p = 0.004) and thrombosis (p = 0.027). The demand for analgesics was significantly lower in the early recovery after surgery group. The amount of food consumed in relation to the amount of food offered was significantly higher for the early recovery after surgery group as early as day 3 (p = 0.02). Time spent in the intermediate care unit was significantly shorter for the early recovery after surgery group (p <0.001). There were no significant differences between the groups with respect to gastrointestinal events. The main limitations of this study were the lack of long-term data as well as the single center approach. CONCLUSIONS: Early recovery after surgery of patients who underwent radical cystectomy appears to have significant benefits compared to a conservative regimen in terms of postoperative morbidity, quality of life, use of analgesics and time spent in the intermediate care unit.

Management of pelvic lymphoceles after radical prostatectomy: a multicentre community based study.

INTRODUCTION: Pelvic lymphoceles (LC) following radical prostatectomy (LC-RP) have an incidence up to 27%. LC-managements constitute 50% of surgical interventions performed in post-RP patients. OBJECTIVES: To describe a therapeutic algorithm for LC-managements based on a community based representative retrospective study. PATIENTS AND METHODS: Multicentre data from 304 patients with LC-RP were retrospectively examined for LC-managements. RPs were performed by various surgeons from 67 urological departments. All patients had undergone 3 weeks rehabilitation in a specialized hospital where the data base was generated. Indications and results of therapeutic manoeuvres were used to develop a general concept for planning therapy decisions. - RESULTS: Median age was 64 years. Complications occurred in 9% (28/304) of patients. Median LC-volume was 36ml (range 20-1800ml). There were more complications for LCs with ≥ 100ml volume than those <100ml (27% versus 17%, p = 0.346). Conservative therapy was the standard in uncomplicated cases (87%, 239 of 276 patients), while intervention was done in 13% (puncture and/or drainage, surgery). Surgical intervention was performed significantly more often in complicated cases (82%, 23 from 28 patients; p<0.001). Based on these data, LCs can be stratified into 3 groups depending on the size and clinical presentation. Therapeutic decisions were used to develop the illustrated new therapy algorithm. CONCLUSIONS: This study based treatment algorithm provides a rationale approach with an accurate LC-classification as regard the indications and decision making for the available LC-RP-therapies. This could facilitate management decisions. Evaluation of this concept prospectively in large patient cohort is mandatory.

[Incontinence surgery-quality criteria and structured follow-up]. / Inkontinenzchirurgie ­ Qualitätskriterien und strukturiertes Follow-up.

The following article summarizes the current evidence including postoperative success rates and complications for various surgical options in the treatment of urinary incontinence. Due to different inclusion criteria and inconsistent definitions of study endpoints, the analysis of available studies is difficult. Thus, comparative studies with new devices for established treatment options should be planned. Structured processes used in certified continence centers improve the quality of care. Furthermore by documenting relevant complications, comparisons of treatment results thus become possible and provide evidence for the use of different surgical options in the treatment of urinary incontinence.

Conservative management of rectal perforation after nerve sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) in a patient with a past history of polypectomy.

INTRODUCTION: Rectal polypectomy causes thinning (or even perforation) of the rectal wall in addition to thermic injury at the polypectomy site. CASE REPORT: We present a rare case of spontaneous rectal perforation after uncomplicated nerve sparing endoscopic extraperitoneal radical prostatectomy in a patient with a previous history of rectal polypectomy at the perforation site. The patient could be treated conservatively. There was complete healing of the fistula without any effect on functional results. This Conservative therapy for such rectal perforations is indicated if the patient's general condition remains stable without any signs of infection. CONCLUSIONS: Polypectomy is an important risk factor for rectal perforation during nsEERPE. Adequate time interval should be given to allow healing and avoid adding further thermal wall damage which may obscure healing leading to complications like fistula. Conservative therapy for small missed rectal perforations constitutes an attractive, feasible and non invasive treatment entity. Following this principle we have not faced this complication in following similar cases.

[Awareness of clinical relevance of malignant testicular cancer among university students : The value of ​prevention campaigns]. / Das Bewusstsein bezüglich der klinischen Relevanz von bösartigen Hodentumoren unter Studierenden : Der Stellenwert von Aufklärungskampagnen.

BACKGROUND: Early detection of localized testicular cancer is associated with a significantly better prognosis compared to advanced tumor stages. Testicular cancer prevention campaigns like "Hodencheck.de" launched by the German Society of Urology or the international campaign "Movember Foundation" want to inform and raise awareness about testicular cancer and other male cancers. This study aimed to evaluate to which extent public prevention campaigns may influence the behavior of young men and women in Germany. OBJECTIVES: Questionnaires were used to ask students at the University of Frankfurt, Germany, whether they are familiar with the currently most widespread testicular cancer prevention campaigns and whether testicular examinations for cancer screening were performed by themselves, a partner or a physician. RESULTS: Only a minority of the students were aware of the testicular cancer prevention campaigns "Hodencheck.de" and/or "Movember Foundation"; 79.9% of the male and 83.6% of female students had not heard of the two mentioned prevention campaigns. Significantly more male (35.2%) compared to female students (28.9%) knew that testicular cancer is the most common cancer in young men. Of the men, 48.9% had already palpated their testicles, while only 12.4% of the women had already palpated the partner's testicles for cancer screening. Students knowing about the testicular cancer prevention campaigns performed significantly more testicular examinations for screening purposes. CONCLUSIONS: Our study demonstrates that current testicular cancer prevention campaigns are little known amongst German university students. However, the knowledge of testicular cancer prevention campaigns resulted in an increased awareness and an increased willingness for testicular (self-) examinations.

Micro-endoscopy of the human vas deferens: a feasibility study of a novel device in several ex vivo models.

The aim of this study was to show limitation as well as potential of micro-endoscopy techniques as an innovative diagnostic and therapeutic approach in andrology. Two kinds of custom-made micro-endoscopes (ME) were tested in ex vivo vas deferens specimen and in post-mortem whole body. The semi-rigid ME included a micro-optic (0.9 mm outer diameter [OD], 10.000 pixels, 120° vision angle [VE], 3-20 mm field depth [FD]) and an integrated fibre-optic light source. The flexible ME was composed of a micro-optic (OD = 0.6 mm, 6.000 pixels, 120° VE, 3-20 mm FD). The ex vivo study included retrograde investigation of the vas deferens (surgical specimen n = 9, radical prostatectomy n = 3). The post-mortem investigation (n = 4) included the inspection of the vas deferens via both approaches. The results showed that antegrade and retrograde rigid endoscopy of the vas deferens were achieved as a diagnostic tool. The working channel enabled therapeutic use including biopsies or baskets. Using the flexible ME, the orifices of the ejaculatory ducts were identified. In vivo cadaveric retrograde cannulation of the orifices was successful. Post-mortem changes of verumontanum hindered the examinations beyond. Orifices were identified shaded behind a thin transparent membrane. Antegrade vasoscopy using flexible ME was possible up to the internal inguinal ring. Further advancement was impossible because of anatomical angle and lack adequate vision guidance. The vas deferens interior was clearly visible and was documented by pictures and movies. Altogether, the described ME techniques were feasible and effective, offering the potential of innovative diagnostic and therapeutic approaches for use in the genital tract. Several innovative indications could be expected.

[Genital herpes]. / Herpes genitalis.

Genital herpes simplex virus (HSV-1 and HSV-2) infection is an ulcerative, lifelong, recurring sexually transmitted disease of increasing epidemiologic worldwide importance. Transmission occurs by close skin contact, usually during asymptomatic virus shedding. The virus persists in the dorsal root ganglion where it is not accessible to the host's immune system. The most important risk factor is a person's number of lifetime sex partners. The more extensive first-episode infection is followed by milder recurrences. Recurrence rates differ greatly. The diagnosis is made clinically, microbiologically, and serologically. There are several virostatic agents available for treatment.

[Vesico-ureteral reflux: Diagnosis and treatment recommendations]. / Vesikoureteraler Reflux : Diagnose und Therapieempfehlungen.

BACKGROUND: Vesico-ureteral reflux (VUR) is one of the most common urologic diseases in childhood. About every third child that presents with a urinary tract infection (UTI) has urinary reflux to the ureter or kidney. Demonstration of a backflow of urine into the ureters or kidneys proves vesicoureteral reflux. In unclear cases, a positioned instillation of contrast agent (PIC) cystogram might be performed and is able to prove vesico-ureteral reflux. OBJECTIVES: Since low-grade VUR has a high probability of maturation and self-limitation, infants with VUR should be given prophylactic antibiotics during their first year of life, reevaluating the status of VUR after 12 months. The aim of any treatment is to prevent renal damage. THERAPY: The individual risk of renal scarring is decisive for the choice of adequate therapy. This risk is mainly dependent on reflux grade, age, and gender of the child as well as parental therapy adherence. In principle, therapeutic options include conservative as well as endoscopic or open surgical antireflux therapies. CONCLUSION: Decisions on treatment should be made individually with parents taking into account all the findings available.

Results of a prospective study comparing the clinical efficacy of cryoablation of renal cell cancer followed by immediate partial nephrectomy.

PURPOSE: Evaluation if cryoablation of small renal tumours (RT) would facilitate the technique of laparoscopic partial nephrectomy (LPN) in a prospective study. PATIENTS AND METHODS: In a prospective non-randomised study between April 2007 and October 2009, 16 patients with a mean age of 68 years (48-80 years) and a peripherally located RT were candidates for nephron-sparing surgery (5 open partial nephrectomy (OPN), 11 LPN). Cryoablation of RT was followed in the same session by open (K-OPN) and laparoscopic (K-LPN) partial nephrectomy. Perioperative and follow-up parameters were estimated. A matched-pair cohort of 41 patients (20 OPN, 21 LPN) who underwent standard operations due to the same indication has been selected for retrospective comparison (controls). RESULTS: Mean age for K-OPN was 74 years (69-83) with mean blood loss 140 ml (50-200); for K-LPN: 66.6 years (48-80) with 100 ml (50-700). All procedures were completed successfully without conversions (K-LPN), transfusions or intra-operative complications. Compared to OPN/LPN, K-OPN and K-LPN were associated with a longer operative time (P < 0.05) and a comparable postoperative hospital stay. There were no early postoperative complications. Cryoablation has not affected the histopathological evaluation of tumours or resection margins. Histopathology showed cytologic changes suggesting fresh coagulative necrosis, glomerular vascular congestion and interstitial haemorrhages following cryotherapy. One patient (K-LPN) developed a pararenal abscess necessitating puncture after 7 weeks. The follow-up (9-42 months) was uneventful. CONCLUSIONS: The current study shows that K-LPN is feasible without increasing procedure morbidity or compromising surgical and oncological outcomes. It adds no advantage to tumour excision. Pathological findings document early cryoablation effects but viable tissue.

[Oncological and functional results of open intrafascial radical prostatectomy]. / Onkologische und funktionelle Ergebnisse der offenen intrafaszialen radikalen Prostatektomie.

BACKGROUND: According to the recently published German-language S3 guidelines, various treatment options such as surgical management or radiation therapy are available to patients with locally advanced prostate cancer. METHODS: Particularly the establishment of minimally invasive endoscopic surgical techniques, which provide better optical images, has made it possible to visualize tissue layers that are usually difficult to identify with the open surgical technique. This contribution describes a pilot study on the establishment of open intrafascial radical prostatectomy. AIM: The goal of the study is to critically analyze both the functional and especially the oncological results, which should not be compromised by the nerve-sparing approach.

[Laparoscopic radical and partial nephrectomy: an overview]. / Laparoskopische radikale und partielle Nephrektomie : Ein Uberblick.

Laparoscopy has been progressively gaining acceptance in the urologic arena. The start with renal surgery was slow; however, after complete establishment for benign indications the breakthrough occurred due to the success of laparoscopy in the field of oncologic surgery. Laparoscopic radical nephrectomy for stage T1 and T2 tumours, whether transperitoneal or retroperitoneal, can be performed safely. The surgical steps duplicate the open procedure. The overall complication rate is low and does not significantly differ from that of the open procedure. Laparoscopic partial nephrectomy is, in contrast, a technically challenging procedure despite its realisation laparoscopically. Although the intermediate outcomes are comparable to those of the open procedure, there are concerns related to warm ischemia time and the risk of major complications such as urinary leakage and haemorrhage requiring transfusion, so that it should be performed only in centres with expertise.

Photodynamic diagnosis of prostate cancer using 5-aminolevulinic acid--first clinical experiences.

OBJECTIVES: To study the feasibility of 5-aminolevulinic-acid (5-ALA)-induced photodynamic diagnosis (PDD) for the evaluation of the surgical margins (SMs) during radical prostatectomy (RP) in patients with prostate cancer (PCa). METHODS: A total of 18 patients with histologically confirmed PCa (Gleason score 4 to 8, prostate-specific antigen 1 to 20 ng/mL) underwent RP. Of the 18 patients, 16 received 5-ALA (20 mg/kg) orally 2 hours before RP, and 2 served as controls without any application of 5-ALA. To study the protoporphyrin IX (PPIX) accumulation after application of 5-ALA, all harvested specimens were investigated by fluorescence microscopy and spectroscopy. In 10 of 16 patients, PDD of the SMs and the prostate was performed during RP using an incoherent light source filtered for efficient fluorescence excitation. RESULTS: In all 16 patients, who had received 5-ALA fluorescence microscopy showed a selective accumulation of PPIX in the PCa cells, and only weak PPIX fluorescence could be detected in benign epithelial cells and none in the adjacent stroma. The 2 patients, who had not received 5-ALA had no PPIX fluorescence in the prostate. Of 10 patients, 8 demonstrated fluorescence-negative and histologically confirmed negative margins during PDD, and 1 each demonstrated a fluorescence-positive SM that was also confirmed by histologic examination and a positive SM that was not confirmed by PPD. CONCLUSIONS: This is the first report of PDD for PCa using 5-ALA. These initial results have demonstrated that PPIX is selectively enhanced in malignant tissue, an essential prerequisite of PDD. Additional studies are warranted to validate these preliminary data and the efficacy of PDD for PCa during RP.