Surgical Reintervention Rates after Invasive Treatment for Lower Urinary Tract Symptoms due to Benign Prostatic Syndrome: A Comparative Study of More than 43,000 Patients with Long-Term Followup.

PURPOSE: No large-scale comparison of the 4 most established surgical approaches for lower urinary tract symptoms due to benign prostate obstruction in terms of long-term efficacy is available. We compared photoselective vaporization, laser enucleation and open simple prostatectomy to transurethral resection with regard to 5-year surgical reintervention rates. MATERIALS AND METHODS: A total of 43,041 male patients with lower urinary tract symptoms who underwent transurethral resection (34,526), photoselective vaporization (3,050), laser enucleation (1,814) or open simple prostatectomy (3,651) between 2011 and 2013 were identified in pseudonymized claims and core data of the German local health care funds and followed for 5 years. Surgical reinterventions for lower urinary tract symptoms, urethral stricture or bladder neck contracture were evaluated. Surgical approach was related to reintervention risk using the Kaplan-Meier method and Cox proportional hazards models. RESULTS: A total of 5,050 first reinterventions were performed within 5 years of primary surgery (Kaplan-Meier survival without reintervention: 87.5%, 95% CI 87.2%-87.8%). Photoselective vaporization carried an increased hazard of reintervention (HR 1.31, 95% CI 1.17-1.46, p <0.001) relative to transurethral resection, open simple prostatectomy carried a lower hazard (HR 0.43, 95% CI 0.37-0.50, p <0.001) and laser enucleation of the prostate did not differ significantly (HR 0.84, 95% CI 0.66-1.08, p=0.2). This pattern was more pronounced regarding reintervention for lower urinary tract symptom recurrence (photoselective vaporization: HR 1.52, 95% CI 1.35-1.72, p <0.001; laser enucleation of the prostate: HR 0.84, 95% CI 0.63-1.14, p=0.3; open simply prostatectomy: HR 0.38, 95% CI 0.31-0.46, p <0.001 relative to transurethral resection). CONCLUSIONS: Five-year reintervention rates of transurethral resection and laser enucleation did not differ significantly, while photoselective vaporization had a substantially higher rate. Open simple prostatectomy remains superior to transurethral resection with respect to long-term efficacy.

National trends and differences in morbidity among surgical approaches for radical prostatectomy in Germany.

OBJECTIVE: In this study, we document trends in radical prostatectomy (RP) employment in Germany during the period 2005-2012 and compare the morbidity of open (ORP), laparoscopic and robotic-assisted RP based on nationwide administrative data of Allgemeine Ortskrankenkassen (AOK) German local healthcare funds. MATERIALS AND METHODS: Administrative claims data of all AOK patients subjected to RP during 2005-2012 (57,156 cases) were used to evaluate the employment of minimally invasive RP (MIRP) procedures, pelvic lymph node dissection (PLND) and nerve-sparing approaches during this period. In addition, data from the most recent three-year period of our dataset (2010-2012) were used to compare the morbidity among the different surgical approaches. Study end points comprised 30-day mortality, 30-day transfusion, 1-year reintervention and 30-day adverse events, as well as 1-year overall complications. RESULTS: A 20 % reduction in RP utilization from 2007 to 2012 was documented. ORP remained the predominant RP approach in Germany. MIRP approaches carried a lower risk of 30-day transfusions, 1-year reinterventions and 1-year overall complications than ORP when adjusting for confounding factors. PLND was associated with an increased risk of complications, while age in the highest quintile and the presence of comorbidities were independent risk factors for morbidity and mortality. Lack of pathological data was the main limitation of the study. CONCLUSIONS: RP utilization in Germany is dropping, but the use of MIRP has risen steadily during the years 2005-2012, which is expected to have a positive impact on the morbidity of the operation.

Paravaginal defect: A new classification of fascial and muscle tears in the paravaginal region.

The lateral support of the vaginal wall depends on the integrity of the paravaginal section of the visceral pelvic fascia, levator ani, and their connection. Various defects of the muscle and fascia can result in identical clinical findings-ie, the descent of the lateral vaginal sulcus. In this study, we created a realistic scheme for classifying paravaginal defects, based on the complex relationship of the pelvic fascia with the levator ani. Surgical observations, cadaver examinations, and a complex magnetic resonance imaging (MRI)-based 3-dimensional (3D) model were used to analyze the spatial relationships of normal and defective anatomy of the female pelvic floor. Descent of the lateral vaginal sulcus can result from a defect in the paravaginal visceral pelvic fascia, levator ani, or both. The fascial defect can be partial or complete, and the muscle defect can vary in location. A detailed illustrated classification is presented. We present a new model of the pathology that underlies a common clinical finding.

Perioperative platelet inhibition in transurethral interventions: TURP/TURB.

PURPOSE: To determine whether transurethral surgery under platelet inhibition is a feasible procedure. Before transurethral resection of prostate (TURP) or bladder tumours (TURB), the administration of platelet-inhibiting medication is often interrupted due to possible bleeding complications. We studied the performance of TURP and TURB under the current recommendations of the American College of Chest Physicians (ACCP) on perioperative platelet inhibition. MATERIALS AND METHODS: Patients assigned for transurethral intervention were preoperatively divided into the following risk groups: low, medium and high cardio- or cerebrovascular risk. In patients with a low-risk profile, acetylsalicylic acid (ASA) was discontinued. Patients of the medium risk group continued taking 100 mg of ASA. Patients of the high-risk group receiving dual platelet inhibition (ASA + clopidogrel) were not treated operatively. In total 346 patients from the low and medium risk groups underwent transurethral intervention. RESULTS: Forty-two out of 198 TURP were performed under 100 mg of ASA. Without ASA, a significantly shorter length of stay and earlier removal of the transurethral catheter was documented. In the parameters postoperative haemorrhage and operative revision, no significant differences were observed. Thirty-two out of 148 TURB were performed under 100 mg of ASA. Regarding the length of stay, time until catheter removal, postoperative haemorrhage and operative revision, no significant differences were found under ASA. Only significantly longer continuous irrigation was documented under ASA. CONCLUSION: In the case of a verified indication for use of platelet inhibitors, it is possible to avoid discontinuation and the consequent increased risk of thromboembolic incidents in transurethral surgery is admissible.

Perioperative platelet inhibition in transurethral interventions: TURP/TURB

PURPOSE: To determine whether transurethral surgery under platelet inhibition is a feasible procedure. Before transurethral resection of prostate (TURP) or bladder tumours (TURB), the administration of platelet-inhibiting medication is often interrupted due to possible bleeding complications. We studied the performance of TURP and TURB under the current recommendations of the American College of Chest Physicians (ACCP) on perioperative platelet inhibition. MATERIALS AND METHODS: Patients assigned for transurethral intervention were preoperatively divided into the following risk groups: low, medium and high cardio- or cerebrovascular risk. In patients with a low-risk profile, acetylsalicylic acid (ASA) was discontinued. Patients of the medium risk group continued taking 100 mg of ASA. Patients of the high-risk group receiving dual platelet inhibition (ASA + clopidogrel) were not treated operatively. In total 346 patients from the low and medium risk groups underwent transurethral intervention. RESULTS: Forty-two out of 198 TURP were performed under 100 mg of ASA. Without ASA, a significantly shorter length of stay and earlier removal of the transurethral catheter was documented. In the parameters postoperative haemorrhage and operative revision, no significant differences were observed. Thirty-two out of 148 TURB were performed under 100 mg of ASA. Regarding the length of stay, time until catheter removal, postoperative haemorrhage and operative revision, no significant differences were found under ASA. Only significantly longer continuous irrigation was documented under ASA. CONCLUSION: In the case of a verified indication for use of platelet inhibitors, it is possible to avoid discontinuation and the consequent increased risk of thromboembolic incidents in transurethral surgery is admissible.

Laparoscopic adrenalectomy in urological centres - the experience of the German Laparoscopic Working Group.

OBJECTIVE: To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain. PATIENTS AND METHODS: The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed. RESULTS: The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively. CONCLUSION: LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.

Intraoperative photodynamic evaluation of surgical margins during endoscopic extraperitoneal radical prostatectomy with the use of 5-aminolevulinic acid.

PURPOSE: Today there are no established techniques to image positive surgical margins (PSM) intraoperatively in endoscopic extraperitoneal radical prostatectomy (EERPE). The intention of this study was to describe the specific technique of photodynamic diagnosis (PDD) in patients undergoing EERPE and report on the potential to detect PSM under PDD. MATERIALS AND METHODS: Twenty-four patients with clinically organ-confined prostate cancer received 5-aminolevulinic acid 20 mg/kg body weight orally 3 hours prior to nonnerve-sparing EERPE. An endoscopic PDD system (Karl Storz, Tuttlingen, Germany) including a Tricam PDD 3-chip camera head linked with a straight 10-mm telescope and a D-light C system was used. During EERPE, visualization of the surgical margins was performed by means of both white light and PDD at specific steps during standardized prostatectomy in all patients. Positive PDD areas on the prostate specimen were marked with white ink and consequently processed in pathology. RESULTS: In white light endoscopy, no suspicion of a PSM was raised. Six out of the eight PSM were detected by PDD. In two cases, areas of positive PDD findings were free of prostate cancer and two PSM were not detected by PDD ( one bladder neck, one lateral). The overall sensitivity and specificity were 75% and 88.2%, respectively. CONCLUSIONS: Laparoscopy offers an appropriate setting for the use of PDD in prostate cancer to visualize possible PSM. Although imaging of PSM by PDD is promising with the technique being feasible and safe, larger series are needed to prove the reproducibility of our results.

The MiniArc sling system in the treatment of female stress urinary incontinence.

AIMS: To assess the technical feasibility of a new mini-invasive sling procedure (MiniArc) and present short-term results in the treatment of female urinary incontinence. MATERIALS AND METHODS: A total of 97 women with mixed or stress urinary incontinence (SUI) were treated by placement of the new single-incision sling. Pelvic organ prolapse was graded using the POP-Q system (pelvic organ prolapse quantification system). Preoperative workup included urodynamic evaluation, cough stress test and introital ultrasound. Postoperatively, introital ultrasound was performed to determine residual urine and check tape position. Quality of life was measured using King's Health Questionnaire. A voiding diary and pad count served to verify the patients' subjective complaints. RESULTS: The MiniArc single-incision sling procedure was the initial intervention in 37 (38.2%) patients and the second intervention in 60 (61.7%) patients with recurrent incontinence. The cough stress test was negative in 79 (83.1%) women 6 weeks after the sling procedure and in 74 (77.8%) at 12 months. De novo urge occurred in 32 (36.8%) women. Quality of life was significantly improved at 12-month follow-up in 65 (69.1%) patients (p < 0.001). The number of pads decreased significantly from 2.2 to 0.6 (p < 0.001) after the procedure. One patient developed an hematoma and bladder perforation occurred in another. CONCLUSIONS: Our short-term clinical results suggest that the MiniArc is a safe and effective minimally invasive sling procedure for treating female SUI. Randomized comparative controlled trials and long-term results are still required to define the role of the new sling system in comparison to established mid-urethral tape techniques for treating incontinence.

The Miniarc® sling system in the treatment of female stress urinary incontinence

AIMS: To assess the technical feasibility of a new mini-invasive sling procedure (MiniArc®) and present short-term results in the treatment of female urinary incontinence. MATERIAL AND METHODS: A total of 97 women with mixed or stress urinary incontinence (SUI) were treated by placement of the new single-incision sling. Pelvic organ prolapse was graded using the POP-Q system (pelvic organ prolapse quantification system). Preoperative workup included urodynamic evaluation, cough stress test and introital ultrasound. Postoperatively, introital ultrasound was performed to determine residual urine and check tape position. Quality of life was measured using King's Health Questionnaire. A voiding diary and pad count served to verify the patients' subjective complaints. RESULTS: The MiniArc® single-incision sling procedure was the initial intervention in 37 (38.2 percent) patients and the second intervention in 60 (61.7 percent) patients with recurrent incontinence. The cough stress test was negative in 79 (83.1 percent) women 6 weeks after the sling procedure and in 74 (77.8 percent) at 12 months. De novo urge occurred in 32 (36.8 percent) women. Quality of life was significantly improved at 12-month follow-up in 65 (69.1 percent) patients (p < 0.001). The number of pads decreased significantly from 2.2 to 0.6 (p < 0.001) after the procedure. One patient developed an hematoma and bladder perforation occurred in another. CONCLUSIONS: Our short-term clinical results suggest that the MiniArc® is a safe and effective minimally invasive sling procedure for treating female SUI. Randomized comparative controlled trials and long-term results are still required to define the role of the new sling system in comparison to established mid-urethral tape techniques for treating incontinence.

Surgical outcomes of fluorescence-guided laparoscopic partial nephrectomy using 5-aminolevulinic acid-induced protoporphyrin IX.

BACKGROUND: To evaluate the clinical performance of photodynamic diagnostic (PDD) after oral administration of 5-aminolevulinic acid (5-ALA) for assessment of tumor type and surgical margins in laparoscopic nephron-sparing surgery. MATERIALS AND METHODS: This is a prospective, non-randomized single-center study. A total of 77 patients with a renal mass < 4 cm diameter underwent laparoscopic partial nephrectomy (LPN). For photosensitization, 1.5 g 5-ALA was administered orally 4 h prior to surgery. During the operation, the resection site and the outer tumor border were inspected under excitation light for characteristic red fluorescence. The results of PDD were matched up to the histological findings. RESULTS: Mean operative time was 94.1 min with a mean warm-ischemia time of 23 min. Fifty-eight of 61 (95.1%) renal cell carcinomas showed a positive response when exposed to excitation light. In 16 cases (21%), final pathology revealed a nonmalignant lesion. However, characteristic fluorescence was also detected in 1 angiomyolipoma of 16 nonmalignant lesions. False-negative rate was 3/61 (4.9%) and false-positive rate was 1/77 (1.3%), with these data corresponding to a sensitivity of 95% and a specificity of 94%. Further, PDD with 5-ALA was able to predict the type of the lesion with an accuracy of 94% and with a positive predictive value of 98%. Furthermore, PDD with 5-ALA also identified both cases with positive resection margins, which were confirmed on histological examinations. No side effects of systemic 5-ALA administration were observed. CONCLUSIONS: PDD after systemic administration of 5-ALA is a reliable tool to assess the type and the resection status of a suspected renal tumor during laparoscopic nephron-sparing surgery.

Photodynamic diagnosis using 5-aminolevulinic acid for the detection of positive surgical margins during radical prostatectomy in patients with carcinoma of the prostate: a multicentre, prospective, phase 2 trial of a diagnostic procedure.

BACKGROUND: Surgical margin status after radical prostatectomy (RP) is a significant risk factor for tumour recurrence. It is an intriguing concept to find a fluorescence marker for photodynamic diagnosis (PDD) to make tumour margins visible during surgery. OBJECTIVE: To investigate the feasibility of identification of positive surgical margins (PSM) during open retropubic or endoscopic extraperitoneal RP by 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX) to enhance surgical radicality. DESIGN, SETTING, AND PARTICIPANTS: Thirty-nine patients (Gleason score 6-10, prostate-specific antigen [PSA] 2.3-120 ng/ml) received 20 mg/kg of body weight of 5-ALA orally and underwent RP (24 endoscopic extraperitoneal, 15 open retropubic). MEASUREMENTS: A PDD-suitable laparoscopy optic (Karl-Storz GmbH, Tuttlingen, Germany) with a yellow long-pass filter was coupled to a fibre-optic light cord with an excitation light source (380-420 nm, D-Light, Karl-Storz GmbH, Tuttlingen, Germany) for fluorescence excitation of PpIX and to a PDD-suitable camera for video and photo documentation by the AIDA DVD system (Karl-Storz GmbH, Tuttlingen, Germany). RESULTS AND LIMITATIONS: There were more false-negative cases in the open group (four vs two) than in the endoscopic group but more false-positive cases in the endoscopic group (two vs none) than in the open group. The overall sensitivity and specificity were 56% and 91.6%, respectively. The sensitivity of the endoscopic cases was much higher (75% vs 38%) than for the open cases, while the specificity was higher for the open group (88.2% vs 100%). CONCLUSIONS: PDD with 5-ALA-induced PpIX during RP might be a feasible and effective method for reducing the rate of PSM. The technique seems to be more practicable during endoscopic RP rather than open RP. Further clinical studies with higher patient volumes and further development of the technique seem justified. TRIAL REGISTRATION: EudraCT: 2005-004406-93.

Asystolic cardiac arrest during balloon insufflation for endoscopic extraperitoneal radical prostatectomy.

BACKGROUND AND PURPOSE: Hemodynamic changes during abdominal laparoscopic procedures have been described as multifactorial phenomena. We report the possible occurrence of bradycardia and asystolic cardiac arrest during insufflation of the balloon trocar as a rare and serious but reversible complication during endoscopic extraperitoneal radical prostatectomy (EERP) for management of localized prostate cancer. PATIENTS AND METHODS: Between 2003 and 2006, 430 patients underwent EERP for localized prostate cancer. The anesthetic protocol was standardized. The EERP was started with creating a preperitoneal space by insufflation of air through a balloon trocar inserted tangentially to the cutaneous plane toward the pubis. RESULTS: Review of the intraoperative data of our patient population revealed the occurrence of bradycardia and/or asystolic cardiac arrest during insufflation of the balloon trocar in three patients. The overall incidence of this complication in our population was therefore 0.7 per 100 patients. Further, during the insufflation of the balloon, a maximum pressure of 120 mm Hg has been measured. CONCLUSIONS: Severe vagal reaction triggered by manipulation of pelvic structures or nerves by the insufflated balloon trocar resulted in asystolic cardiac arrest in three patients. The life-threatening nature of this phenomenon should be understood by all anesthesiologists and urologists engaged in laparoscopic procedures.

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.

Mitogenic and anti-apoptotic actions of adipocyte-derived hormone leptin in prostate cancer cells.

OBJECTIVE: To investigate the proliferative and anti-apoptotic effects of leptin on human prostate cancer cells, and the role of related signalling pathways in mediating these actions, as obesity is a possible risk factor for prostate cancer and leptin, an adipocyte-derived hormone, has mitogenic action in various cell types. MATERIALS AND METHODS: Two human prostate cancer cell lines, DU145 and PC-3, were treated with leptin (5-100 ng/mL) for up to 48 h. Under serum-free conditions, cell proliferation was measured using a colorimetric tetrazolium assay and apoptosis by an enzyme-linked immunosorbent assay measuring cell death. Also, the phosphorylation of ERK1/2 and Akt was detected by Western blotting, and specific inhibitors of mitogen-activated protein kinase (MAPK) (PD98059; 40 microm) and phosphatidylinositol 3-kinase (PI3-K, LY294002; 40 microm) were used to evaluate the role of these signalling pathways. RESULTS: Leptin dose-dependently increased the cell number in both cell lines for up to 48 h of incubation, the mean (sem) percentage of the control being 189 (4.3)% for DU145 and 173 (7.5)% for PC-3 (100 ng/mL leptin, 48 h; P < 0.01). Leptin also significantly reduced the number of apoptotic cells after 24 h of treatment, dose-dependently caused ERK1/2 and Akt phosphorylation; pretreatment with inhibitors of MAPK and PI3-K inhibited these responses. CONCLUSION: These results show that chronic increases in leptin might enhance the growth of prostate cancer via the MAPK and PI3-K pathways. Further studies are needed to investigate whether the ability of leptin to stimulate mitogenic/anti-apoptotic signal transduction pathways could represent a target for anticancer drug discovery.

Maintaining perioperative normothermia during laparoscopic and open urologic surgery.

PURPOSE: The ability to maintain normothermia during surgical procedures is crucial for improvement of the quality of patient care and the outcome of the procedure. We tested the hypothesis of whether one warming protocol is able to maintain normothermic core temperatures equally well in major open and laparoscopic urologic procedures. PATIENTS AND METHODS: In this prospective study, 300 patients who were scheduled for open (n=53) or laparoscopic (n=247) urologic procedures were included and received intraoperative warming using a combination of an upper and lower body forced-air warmer and a single warming blanket. Core temperature was measured at baseline, at induction of anesthesia, at the start of the operation, and at the end of the operation. RESULTS: A significant improvement in core temperature during the operation was achieved in all patients (P<0.001). There was no difference in the end-of-operation core temperature between laparoscopic and open procedures: (36.29 degrees C+/-0.03 degrees C v 36.23 degrees C+/-0.06 degrees C; P=0.224). Further, 23.3% of all patients had a core temperature of lower than 36.0 degrees C at the end of the operation (laparoscopy 23.8% v open 26.6%). Linear regression analysis revealed a correlation between duration of the operation and intraoperative core temperature (P<0.001). CONCLUSION: The present warming protocol is effective in maintaining perioperative normothermia during major open and laparoscopic urologic procedures.

Laparoscopic cystectomy with extracorporeal-assisted urinary diversion: experience with 34 patients.

OBJECTIVES: Open radical cystectomy remains the gold standard for nonmetastatic muscle invasive bladder cancer. Laparoscopic cystectomy has been described as a feasible procedure and is still being evaluated. We describe our initial experience with this laparoscopic surgical approach in 34 patients. METHODS: From February 2002 to October 2004, 18 men and 16 women underwent laparoscopic cystectomy with extracorporeal-assisted urinary diversion for transitional cell carcinoma of the bladder (n=27), invasive cervical carcinoma (n=4), and atrophic bladder (n=3). We report here on specific technical details and present initial results of our series. RESULTS: The mean operating time was 244 min, the mean blood loss 325 ml, and the transfusion rate 5.9%. All procedures were completed laparascopically without conversion to open techniques. No major complications occurred during or after the operation. In case of urothelial malignancy (n=27), the histopathologic analysis of the removed specimen revealed organ-confined transitional cell carcinoma of the bladder in 66.7% (pT1:14.8%; pT2: 51.9%) and locally advanced disease in 33.3% (pT3: 25.9%; pT4: 7.4%). In two cases final histology proved positive surgical margins. Extended lymphadenectomy detected lymph node metastasis in two patients. CONCLUSIONS: We demonstrate that the combination of laparoscopic cystectomy and extracorporeal urinary diversion is possible and remains a safe, feasible, and repeatable surgical technique. To determine the oncologic outcome long-time follow-up will be necessary.

Laparoscopic radical prostatectomy--the experience of the German Laparoscopic Working Group.

PURPOSE: To present the current status of laparoscopic radical prostatectomy (LRP) in Germany, Austria and Switzerland with respect to transferability, learning curve, and outcome. MATERIAL AND METHODS: The data of 5824 patients who underwent LRP in 18 centers by 50 urologists from March 1999 to August 2004 were analyzed retrospectively. Three centers performed more than 500, and six more than 250 cases. A transperitoneal descending technique with was used in 2701, a transperitoneal ascending in 1234, an extraperitoneal descending in 1814, and an extraperitoneal ascending modification in 75 cases. Specimen showed pT2 in 3535, pT3a in 1555, pT3b in 623, and pT4 in 111 cases. RESULTS: Mean operating time averaged 211 (131-292) minutes, with shorter duration of the extraperitoneal descending technique. Conversion to open surgery averaged 2.4 (0-14.1) %. Re-intervention rate amounted to 2.7 (0.3-7.7) %. Complication rate averaged 8.9 (1.8-10.8) % including bleeding (0.3-2.5%) and rectal lesion (1.5-2.5%). The rate of positive margins was 10.6 (3.2-18) % for pT2- and 32.7 (20-38.5) % for pT3a-tumors Continence after 12 months was 84.9 (72-94) %. Data about potency (7 centers) revealed 52.5 (35-67) % full erections following bilateral nerve preservation. 5 year-PSA recurrence rate (3 centers) was 8.6 (4-15.3) % for pT2-tumors and 17.5 (15-20.6) % for pT3a-stages. CONCLUSIONS: The results confirm the efficacy of the training program with safe transfer of LRP (i.e. low complication rate), however including all known problems of a retrospective study.

Improved detection and treatment of bladder cancer using hexaminolevulinate imaging: a prospective, phase III multicenter study.

PURPOSE: We determined if improved tumor detection using hexaminolevulinate (HAL) fluorescence cystoscopy could lead to improved treatment in patients with bladder cancer. MATERIALS AND METHODS: A total of 146 patients with known or suspected bladder cancer were assessed in this open, comparative, within patient, controlled phase III study. Patients received intravesical HAL for 1 hour and were assessed with standard white light cystoscopy and blue light fluorescence cystoscopy. All lesions were mapped onto a bladder chart and biopsies were taken from suspicious areas for assessment by an independent pathologist. An independent urologist blinded to the detection method used recommended treatment plans based on biopsy results and medical history according to European Association of Urology bladder cancer guidelines. Any differences in recommended treatment plans arising from the 2 cystoscopy methods were recorded. RESULTS: HAL imaging improved overall tumor detection. Of all tumors 96% were detected with HAL imaging compared with 77% using standard cystoscopy. This difference was particularly noticeable for dysplasia (93% vs 48%), carcinoma in situ (95% vs 68%) and superficial papillary tumors (96% vs 85%). As a result of improved detection, additional postoperative procedures were recommended in 15 patients (10%) and more extensive treatment was done intraoperatively in a further 10. Overall 17% of patients received more appropriate treatment at the time of the study following blue light fluorescence cystoscopy, that is 22% or 1 of 5 if patients without tumors were excluded. CONCLUSIONS: HAL imaging is more effective than standard white light cystoscopy for detecting bladder tumors and lesions. This leads to improved treatment in a significant number of patients (p <0.0001).

Diagnosis of urothelial carcinoma of the bladder using fluorescence endoscopy.

Bladder cancer is a frequent disease and represents the second most common genitourinary neoplasm. Although many aspects of the management of superficial bladder cancer are now well established, significant challenges remain, which influences patient outcome. Early detection and treatment of recurrent disease is required to optimize bladder preservation, reduce patient morbidity, and increase quality of life and survival. Fluorescence endoscopy, often referred to as 'photodynamic diagnosis' (PDD), with intravesical application of photosensitizing agents, has been developed to enhance the early detection of bladder cancer. There is growing evidence that PDD using 5-aminolaevulinic acid (ALA), hexyl-ALA ester or hypericin enhances the detection of bladder cancer, particularly of high-grade flat lesions. Furthermore, transurethral resection of bladder tumour under fluorescence guidance reduces the risk of recurrent tumours. However, the impact on the progression of disease remains unclear and must be investigated in prospective randomized trials.