First completely robot-assisted retroperitoneal nephroureterectomy with bladder cuff: a step-by-step technique.

INTRODUCTION: While various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity. We developed a novel port placement and technique allowing to perform robot-assisted NU by a unique retroperitoneal approach. METHODS: Between February and June 2021 patients with history of UTUC were treated by robot-assisted NU completely restricted to retroperitoneal space using a singular trocar placement and a two-step docking without relocation of the surgical robot. Patient characteristics, perioperative outcomes and short-term follow-up were prospectively analyzed. RESULTS: The analysis included five patients [median age: 73 years; BMI: 27.2 kg/m2; Charlson comorbidity index 5]. All five patients had UTUC with a mean tumor size of 3.02 cm (range 0.9-6.0). UTUC was localized to distal ureter in two and to kidney in three cases. No positive surgical margins were noted for all patients with UTUC [1 low-grade and 4 high-grade]. Retroperitoneal lymphadenectomy in three patients did not reveal positive nodes. No intraoperative adverse events exceeding EAUiaiC classification ≥ 2 were observed, while median EBL was 150 ml (IQR 100-250). No patient experienced postoperative complications exceeding Clavien-Dindo classification ≥ 3a. Median hospital stay was 5.4d without any 30-d readmission. CONCLUSION: We demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is easily reproducible, while surgical outcomes are similar to other established techniques.

Robot-assisted simple prostatectomy versus open simple prostatectomy: a single-center comparison.

PURPOSE: Open simple prostatectomy (OSP) is a standard surgical technique for patients with benign prostatic hyperplasia with prostate size larger than 80 ml. As a minimally invasive approach, robot-assisted simple prostatectomy (RASP) emerged as a feasible surgical alternative. Currently, there are no definite recommendations for the standard use of RASP. Therefore, we aimed at investigating various clinical outcomes comparing RASP with OSP. METHODS: In this retrospective single-center study, we evaluated clinical data from 103 RASP and 31 OSP patients. Both cohorts were compared regarding different clinical characteristics with and without propensity score matching. To detect independent predictive factors for clinical outcomes, multivariate logistic regression analysis was performed. RESULTS: Robot-assisted simple prostatectomy patients demonstrated a lower estimated blood loss and need for postoperative blood transfusions as well as less postoperative complications. OSP had a shorter operative time (125 min vs. 182 min) longer hospital stay (11 days vs. 9 days) and longer time to catheter removal (8 days vs. 6 days). In the multivariate analysis, RASP was identified as an independent predictor for longer operative time, lower estimated blood loss, shorter length of hospital stay, shorter time to catheter removal, less postoperative complications and blood transfusions. CONCLUSION: Robot-assisted simple prostatectomy is a safe alternative to OSP with less perioperative and postoperative morbidity. Whether OSP (shorter operative time) or RASP (shorter length of hospital stay) has a more favorable economic impact depends on the particular conditions of different health care systems. Further prospective comparative research is warranted to define the value of RASP in the current surgical management of benign prostatic hyperplasia.

Comparison of adjustable male slings and artificial urinary sphincter in the treatment of male urinary incontinence: a retrospective analysis of patient selection and postoperative continence status.

PURPOSE: To analyze and compare preoperative patient characteristics and postoperative results in men with stress urinary incontinence (SUI) selected for an adjustable male sling system or an artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. METHODS: 658 male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in this study (n = 176 adjustable male sling; n = 482 AUS). Preoperative patient characteristics and postoperative outcomes were analyzed. For statistical analysis, the independent T test and Mann-Whitney U test were used. RESULTS: Patients undergoing adjustable male sling implantation were less likely to have a neurological disease (4.5% vs. 8.9%, p = 0.021), a history of urethral stricture (21.6% vs. 33.8%, p = 0.024) or a radiation therapy (22.7% vs. 29.9%, p = 0.020) compared to patients that underwent AUS implantation. Mean pad usage per day (6.87 vs. 5.82; p < 0.00) and the ratio of patients with a prior incontinence surgery were higher in patients selected for an AUS implantation (36.7% vs. 22.7%; p < 0.001). At maximum follow-up, patients that underwent an AUS implantation had a significantly lower mean pad usage during daytime (p < 0.001) and nighttime (p = 0.018). Furthermore, the patients' perception of their continence status was better with a subjective complete dry rate of 57.3% vs. 22.0% (p < 0.001). CONCLUSIONS: Patients selected for an AUS implantation showed a more complex prior history and pathogenesis of urinary incontinence as well as a more severe grade of SUI. Postoperative results reflect a better continence status after AUS implantation, favoring the AUS despite the more complicated patient cohort.

Clinical outcomes and costs of reusable and single-use flexible ureterorenoscopes: a prospective cohort study.

The purpose of this study is to analyze clinical outcomes and costs of single-use flexible ureterorenoscopes in comparison with reusable flexible ureterorenoscopes in a tertiary referral center. Prospectively, 68 flexible ureterorenoscopies utilizing reusable (Flex-X2S, Flex-XC, Karl Storz) and 68 applying single-use flexible ureterorenoscopes (LithoVue, Boston Scientific) were collected. Clinical outcome parameters such as overall success rate, complication rates according to Clavien-Dindo, operation time and radiation exposure time were measured. Cost analysis was based on purchase costs and recurrent costs for repair and reprocessing divided by number of procedures. In each group 68 procedures were available for evaluation. In 91% of reusable and 88% of single-use ureterorenoscopies stone disease was treated with a mean stone burden of 101 ± 226 and 90 ± 244 mm2 and lower pole involvement in 47 and 41%, respectively (p > 0.05). Comparing clinical outcomes of reusable vs. single-use instruments revealed no significant difference for overall success rates (81 vs. 87%), stone-free rates (82 vs. 85%), operation time (76.2 ± 46.8 vs. 76.8 ± 40.2 min), radiation exposure time (3.83 ± 3.15 vs. 3.93 ± 4.43 min) and complication rates (7 vs. 17%) (p > 0.05). A wide range of repair and purchase costs resulted in total to $1212-$1743 per procedure for reusable ureterorenoscopy whereas price of single-use ureterorenoscopy was $1300-$3180 per procedure. The current work provided evidence for equal clinical effectiveness of reusable and single-use flexible ureterorenoscopes. Partially overlapping ranges of costs for single-use and reusable scopes stress the importance to precisely know the expenses and caseload when negotiating purchase prices, repair prices and warranty conditions.

From novice to expert: analyzing the learning curve for MRI-transrectal ultrasonography fusion-guided transrectal prostate biopsy.

PURPOSE: To investigate the learning curve of a novice in MRI/TRUS software fusion biopsy and to compare his results with the expert standard at our institution. METHODS: Overall 126 MRI/TRUS fusion-guided transrectal biopsies were performed using an electromagnetic tracking ultrasonography platform. The learning progress of the novice was evaluated comparing his initial 42 procedures (group A) with his following 42 (group B). The institution's expert standard (group C), which was compared to the novice's groups, was defined by the expert's experience of 42 MRI/TRUS fusion biopsies. Primary learning curve parameters were targeted biopsy detection quotient and biopsy time. RESULTS: Overall detection of prostate cancer was 64% (27/42), 62% (26/42) and 62% (26/42) in groups A, B and C, respectively. The median target biopsy detection quotient significantly increased (p = 0.04) in group B (0.75, interquartile range (IQR) 0.25-1.0) compared to group A. (0.33, IQR 0.2-0.5). Group C revealed a median detection quotient of 0.5 (IQR 0.25-0.76) that did not differ significantly from the novice's groups (p = 0.2). Median biopsy time was significantly higher in group A (45 min, IQR 33-50 min) compared to groups B (25 min, IQR 23-29 min) and C (24 min, IQR 16-46 min) (p < 0.01). CONCLUSIONS: The present study revealed the individual learning curve of a novice in MRI/TRUS fusion biopsy and demonstrated significant learning progress regarding targeted biopsy detection quotient and biopsy time.

[Renal cell carcinoma: Drug therapy and prognostic models]. / Nierenzellkarzinom : Medikamentöse Therapie und prognostische Modelle.

Renal cell carcinoma (RCC) represents the sixth-leading cancer-specific cause of death worldwide. This is mainly caused by metastatic or locally advanced RCC. Approximately 25-30% of patients present with metastasis during the initial diagnosis. Furthermore, 20-30% of patients develop metastatic disease following initial curative surgery. Metastatic RCC is characterized by a poor prognosis with a median overall survival of less than 2 years. Today, targeted therapies such as VEGF receptor inhibitors and antagonists as well as mTOR inhibitors represent the standard of care in metastatic RCC. Conventional chemotherapies or cytokine-based medications have been abandoned due to inferior clinical efficacy compared with targeted therapies. In Germany, sunitinib, pazopanib, temsirolimus, and bevacizumab have been approved for first-line treatment and sorafenib, axitinib, and everolimus for second-line treatment. Prognostic models, assessing individual risk profiles, have been developed in the last 15 years, which are crucial for the design of trials, patient counseling, and initiation of goal-directed therapies.

[Therapy of overactive bladder (OAB)]. / Therapie der überaktiven Blase (OAB).

Overactive bladder (OAB) is a symptom complex which is present in approximately 17% of the European population. It is observed in the presence or absence of incontinence (wet or dry) and is associated with a high degree of psychological stress as well as high costs for the healthcare system. Myogenic, urothelial and neurogenic factors lead to frequently unknown changes of muscular, neural and connective tissue. For the definition, etiology and diagnostics of the disease the previous continuing medical education (CME) article "Diagnosis of overactive bladder (OAB)" should be consulted. In recent years some improvements have been made in OAB-related research, in terms of pathophysiological models and new pharmacological approaches with the development of new therapeutic agents. Besides classical substances, recently approved agents are increasingly being used for the therapy of OAB. Furthermore, non-pharmaceutical approaches and surgical techniques still play an important role in the therapy of OAB.

[Diagnosis of overactive bladder (OAB)]. / Diagnostik der überaktiven Blase (OAB).

Overactive bladder (OAB) is a symptom complex which is present in approximately 17% of the European population. It is observed in the presence or absence of incontinence (wet or dry) and is associated with a high degree of psychological stress as well as high costs for the healthcare system. Myogenic, urothelial and neurogenic factors lead to frequently unknown changes of muscular, neural and connective tissue. The diagnosis of OAB is empirical and can be used as a basis for initial treatment, while lower urinary tract symptoms have to be evaluated up front. As there are no established biomarkers for OAB, a definitive diagnosis is problematic. It is important to carry out routine diagnostics including a detailed medical history and if needed urodynamic evaluation of the patient. Therapy of OAB will be the topic of a further continuing medical education (CME) article entitled "Therapy of overactive bladder (OAB)".

[Prevention of postprostatectomy incontinence: etiology and risk factors]. / Verhinderung der Postprostatektomieinkontinenz: Ätiologie und Risikofaktoren.

The prevention of postprostatectomy incontinence has always been a challenge for urologists. Improved understanding of male continence and changes in pelvic anatomy after radical prostatectomy and the implementation of new surgical techniques raised hope of reduced incontinence rates. Despite using the full potential of continence-sparing techniques and atraumatic robot-assisted surgery, postprostatectomy incontinence still occurs in 5-20 % of cases. Recently published data showed a trend of improved early return to continence using anterior suspension or posterior reconstruction in robot-assisted prostatectomy. Postprostatectomy incontinence has a negative impact on quality of life and causes high costs of treatment. Therefore, further research in the amelioration of postoperative continence is mandatory.

[Fusion imaging in urology: combination of MRI and TRUS for detection of prostate cancer]. / Fusionsbildgebung in der Urologie: Die Kombination von MRT und TRUS zur Detektion des Prostatakarzinoms.

Multiparametric magnetic resonance imaging (MRI) represents the most accurate imaging modality for prostate cancer imaging to date. Transrectal ultrasound (TRUS) is easily applied and therefore remains the gold standard for systematic prostate biopsies. However, the advantages of both modalities can be combined by image fusion. Currently, several image fusion devices are being implemented into clinical routine. First data show an increased detection rate of prostate cancer compared to systematic TRUS biopsies. At present prostatic deformation and intracorporeal movement represent technical challenges yet to be overcome. The present article gives an overview about the status of MRI-based biopsy techniques and highlights the current studies on the topic.

[Differential diagnosis of multilocular bladder tumors in young patients: nephrogenic adenoma of the bladder in a 25-year old male cystinuria patient]. / Differentialdiagnose multilokulärer Blasentumoren bei jungen Patienten : Nephrogene Adenome in der Harnblase eines 25-jährigen Patienten mit Zystinurie.

The occurrence of malignant neoplasms of the urinary tract in patients below the age of 40 years is rare. Nevertheless, finding masses with suspicious malignant appearance in young patients should alert the examiner particularly against the background of reported cases of urothelial or urachal carcinoma in childhood or adolescence. This report presents the case of a 25-year-old male patient with recurrent urolithiasis due to cystinuria. During elective stone therapy via ureteroscopy a tumor of distinct malignant appearance was conspicuous and was immediately resected. The histopathological findings revealed the diagnosis of a nephrogenic adenoma.

Resistance to the mTOR-inhibitor RAD001 elevates integrin α2- and ß1-triggered motility, migration and invasion of prostate cancer cells.

BACKGROUND: Inhibitors of the mammalian target of rapamycin (mTOR) might become a novel tool to treat advanced prostate cancer. However, chronic drug exposure may trigger resistance, limiting the utility of mTOR inhibitors. METHODS: Metastatic potential of PC3 prostate cancer cells, susceptible (PC3(par)) or resistant (PC3(res)) to the mTOR-inhibitor RAD001 was investigated. Adhesion to vascular endothelium or immobilised collagen, fibronectin and laminin was quantified. Motility, migration and invasion were explored by modified Boyden chamber assay. Integrin α and ß subtypes were analysed by flow cytometry, western blotting and real-time PCR. Integrin-related signalling, EGFr, Akt, p70S6kinase and ERK1/2 activation were determined. RESULTS: Adhesion was reduced, whereas motility, migration and invasion were enhanced in PC3(res). The α2 and ß1 integrin subtypes were dramatically elevated, integrins α1 and α6 were lowered, whereas α5 was nearly lost in PC3(res). Activation of the Akt signalling pathway was strongly upregulated in these cells. Treating PC3(par) cells with RAD001 reduced motility, migration and invasion and deactivated Akt signalling. Blocking studies revealed that α2 and ß1 integrins significantly trigger the motile behaviour of the tumour cells. CONCLUSION: Chronic RAD001 treatment caused resistance development characterised by distinct modification of the integrin-expression profile, driving prostate cancer cells towards high motility.

[Diagnosis and treatment of overactive bladder, neurourology, urogynaecology and urinary stress incontinence: latest publications from 2009 and 2010]. / Uberaktive Blase, Neurourologie, Urogynäkologie und Belastungsinkontinenz: Diagnostik und Therapie--aktuelle Veröffentlichungen aus dem Jahren 2009 und 2010.

The current review presents a summary of the most important manuscripts concerning the topics of overactive bladder, neurourology, genital prolapse and male and female urinary stress incontinence published in the year 2009 and the first 4 months of 2010 in peer-reviewed journals. The literature research was focussed on clinically relevant human studies with influence on diagnosis and therapeutic strategies of these diseases.Most of the published manuscripts focussed on the fields of overactive bladder and female urinary stress incontinence during the last 16 months. Some of the studies had very high evidence levels and confirmed new therapeutic strategies. Publications focussing on male urinary stress incontinence were of limited numbers in the year 2009 and did not change the clinical armamentarium significantly.

[Reconstructive pelvic surgery. Current status and future perspectives]. / Rekonstruktive Beckenbodenchirurgie. Aktueller Stand und Perspektiven.

Pelvic organ prolapse is a widespread condition that especially affects women. There are a number of conservative and surgical therapeutic options. The choice of therapy should be individually made, depending on factors such as the grade of prolapse and concomitant secondary disorders as well as the age and general condition of the patient. This article presents current surgical options, analyzes recent studies, and offers future perspectives for reconstructive pelvic surgery.

[Paraneoplastic syndrome in renal cell carcinoma]. / Paraneoplastische Syndrome des Nierenzellkarzinoms.

Renal cell carcinoma associated paraneoplastic symptoms include constitutional symptoms as well as specific metabolic and biochemical abnormalities. These are present in up to 40% of patients with renal cell carcinoma during the course of the disease. This report provides information on the most common manifestations and their therapy; some rare variants are also mentioned. The importance of paraneoplasia lies partly in the fact that paraneoplastic symptoms may be the precursor of either primary or recurrent disease. The presence of paraneoplastic manifestations does not necessarily imply a poor prognosis or metastatic disease.

[Brain metastases in cases of renal cell carcinoma]. / Hirnmetastasen beim Nierenzellkarzinom.

Brain metastases represent the most common intracranial neoplasia. The lung, breast and kidney are the primary tumor locations most often associated with brain metastasis. Seizures and neurological impairment are typical manifestations of neoplastic cerebral dissemination, which, when untreated, usually lead to death within a few months. In this review, we discuss whole brain radiotherapy, surgical resection and stereotactic radiosurgery as the currently used therapeutic options for renal cell cancer metastasis in the brain.

[Palliative and supportive therapy in cases of renal cell carcinoma]. / Palliative und supportive Therapie des Nierenzellkarzinoms.

At the time of diagnosis, 25-30% of all patients with renal cell carcinoma already present with metastatic disease. Furthermore, 20-30% of patients with renal cell carcinoma will have progressive disease despite radical nephrectomy with complete tumor resection. In this review, we discuss the current therapeutic options for patients with metastatic renal cell carcinoma: These include palliative radical nephrectomy, surgery of metastasis, tumor embolisation and medical treatment options (e.g. immunotherapy, chemotherapy and targeted therapy), as well as supportive pain treatment.