[Digitalization in urology-challenge and opportunity]. / Digitalisierung in der Urologie ­ Herausforderung und Chance.

Digitalization is changing medicine. In Germany these changes are not highly accepted yet. Medical pathways should be supported and become safer by digital transformation. Furthermore, artificial intelligence (AI) applications are increasingly used in medicine. Only time will tell whether these will decrease the workload and make patient treatment easier, while increasing precision and individualization.. Urology must accept the upcoming new challenges. This can best be done by participating in the development.

Insufficient utilization of care in male incontinence surgery: health care reality in Germany from 2006 to 2020 and a systematic review of the international literature.

PURPOSE: Data suggest that the utilization of care in male incontinence surgery (MIS) is insufficient. The aim of this study was to analyse the utilization of care in MIS from 2006 to 2020 in Germany, relate this use to the number of radical prostatectomies (RP) and provide a systematic review of the international literature. METHODS: We analysed OPS codes using nationwide German billing data and hospitals' quality reports from 2006 to 2020. A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). RESULTS: MIS increased by + 68% from 2006 to 2011 (1843-3125; p = 0.009) but decreased by - 42% from 2011 to 2019 (3104-1799; p < 0.001). In 2020, only 1435 MISs were performed. In contrast, RP increased from 2014 to 2019 by 33% (20,760-27,509; p < 0.001). From 2012 to 2019, the number of artificial urinary sphincters (AUSs) changed minimally (- 12%; 1291-1136; p = 0.02). Sling/sling systems showed a decrease from 2011 to 2019 (- 68% 1632-523; p < 0.001). In 2019, 63% of patients received an AUS, 29% sling/sling systems, 6% paraurethral injections, and 2% other interventions. In 2019, few high-volume clinics [n = 27 (13%)] performed 55% of all AUS implantations, and few high-volume clinics [n = 10 (8%)] implanted 49% of retropubic slings. CONCLUSION: MIS have exhibited a relevant decrease since 2011 despite the increase in RP numbers in Germany, indicating the insufficient utilization of care in MIS. The systematic review shows also an international deficit in the utilization of care in MIS.

[Acceptance and status of digitalization in clinics and practices : Current assessment in German urology]. / Akzeptanz und Stand der Digitalisierung in Klinik und Praxis : Aktuelles Stimmungsbild in der deutschen Urologie.

BACKGROUND: Digitalization of patient documentation and introduction of the electronic patient record (ePA) pose challenges to everyday clinical practice. OBJECTIVES: We investigated the acceptance and status of the digitalization of patient data and the introduction of the ePA among German urologists. MATERIALS AND METHODS: A questionnaire with 30 questions about the acceptance and status of digitalization of patient documentation and ePA was sent out via the newsletter of the German Society of Urology. RESULTS: A total of 80 urologists participated in the survey (response rate 2%). Digital platforms such as Urotube or Researchgate are used by 63% of participants. The complete implementation of digital patient documentation was reported by 72% of respondents working in medical practice and by 54% of those working in the hospital (p = 0.042). While 76% see the digitalization process as reasonable, 34% expressed partial or strong concerns about the complete digitalization of patient documentation. Only 14% of the participants offer video consultations. Advantages for ePA include better networking of the healthcare system (73%), improved diagnosis, indication (41%) and treatment quality (48%), and avoidance of medication errors (70%). CONCLUSION: German urologists are open to the digitalization process and ePA. Especially younger urologists are using digital media. The advantages of digitalization are, in particular, an improvement in treatment processes. For a smooth introduction, a cross-departmental establishment and, if necessary, an adaptation of the treatment processes are necessary.

A Multicenter Randomized Noninferiority Trial Comparing GreenLight-XPS Laser Vaporization of the Prostate and Transurethral Resection of the Prostate for the Treatment of Benign Prostatic Obstruction: Two-yr Outcomes of the GOLIATH Study.

BACKGROUND: The GOLIATH study is a 2-yr trial comparing transurethral resection of prostate (TURP) to photoselective vaporization with the GreenLight XPS Laser System (GL-XPS) for the treatment of benign prostatic obstruction (BPO). Noninferiority of GL-XPS to TURP was demonstrated based on a 6-mo follow-up from the study. OBJECTIVE: To determine whether treatment effects observed at 6 mo between GL-XPS and TURP was maintained at the 2-yr follow-up. DESIGN, SETTING, AND PARTICIPANTS: Prospective randomized controlled trial at 29 centers in nine European countries involving 281 patients with BPO. INTERVENTION: Photoselective vaporization using the 180-W GreenLight GL-XPS or conventional (monopolar or bipolar) TURP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the International Prostate Symptom Score for which a margin of three was used to evaluate the noninferiority of GL-XPS. Secondary outcomes included Qmax, prostate volume, prostate specific antigen, Overactive Bladder Questionnaire Short Form, International Consultation on Incontinence Questionnaire Short Form, occurrence of surgical retreatment, and freedom from complications. RESULTS AND LIMITATIONS: One hundred and thirty-six patients were treated using GL-XPS and 133 using TURP. Noninferiority of GL-XPS on International Prostate Symptom Score, Qmax, and freedom from complications was demonstrated at 6-mo and was sustained at 2-yr. The proportion of patients complication-free through 24-mo was 83.6% GL-XPS versus 78.9% TURP. Reductions in prostate volume and prostate specific antigen were similar in both arms and sustained over the course of the trial. Compared with the 1(st) yr of the study, very few adverse events or retreatments were reported in either arm. Treatment differences in the Overactive Bladder Questionnaire Short Form observed at 12-mo were not statistically significant at 24-mo. A limitation was that patients and treating physicians were not blinded to the therapy. CONCLUSIONS: Twenty-four-mo follow-up data demonstrated that GL-XPS provides a durable surgical option for the treatment of BPO that exhibits efficacy and safety outcomes similar to TURP. PATIENT SUMMARY: The long-term effectiveness and safety of GLP-XLS was similar to conventional TURP for the treatment of prostate enlargement.

A European multicenter randomized noninferiority trial comparing 180 W GreenLight XPS laser vaporization and transurethral resection of the prostate for the treatment of benign prostatic obstruction: 12-month results of the GOLIATH study.

PURPOSE: We present the 1-year results of the GOLIATH prospective randomized controlled trial comparing transurethral resection of the prostate to GreenLight XPS for the treatment of men with nonneurogenic lower urinary tract symptoms due to prostate enlargement. The updated results at 1 year show that transurethral resection of the prostate and GreenLight XPS remain equivalent, and confirm the therapeutic durability of both procedures. We also report 1-year followup data from several functional questionnaires (OABq-SF, ICIQ-SF and IIEF-5) and objective assessments. MATERIALS AND METHODS: A total of 291 patients were enrolled at 29 sites in 9 European countries. Patients were randomized 1:1 to undergo GreenLight XPS or transurethral resection of the prostate. The trial was designed to evaluate the hypothesis that GreenLight XPS is noninferior to transurethral resection of the prostate on the International Prostate Symptom Score at 6 months. Several objective parameters were assessed, including maximum urinary flow rate, post-void residual urine volume, prostate volume and prostate specific antigen, in addition to functional questionnaires and adverse events at each followup. RESULTS: Of the 291 enrolled patients 281 were randomized and 269 received treatment. Noninferiority of GreenLight XPS was maintained at 12 months. Maximum urinary flow rate, post-void residual urine volume, prostate volume and prostate specific antigen were not statistically different between the treatment arms at 12 months. The complication-free rate at 1 year was 84.6% after GreenLight XPS vs 80.5% after transurethral resection of the prostate. At 12 months 4 patients treated with GreenLight XPS and 4 who underwent transurethral resection of the prostate had unresolved urinary incontinence. CONCLUSIONS: Followup at 1 year demonstrated that photoselective vaporization of the prostate produced efficacy outcomes similar to those of transurethral resection of the prostate. The complication-free rates and overall reintervention rates were comparable between the treatment groups.

180-W XPS GreenLight laser vaporisation versus transurethral resection of the prostate for the treatment of benign prostatic obstruction: 6-month safety and efficacy results of a European Multicentre Randomised Trial--the GOLIATH study.

BACKGROUND: The comparative outcome with GreenLight (GL) photoselective vaporisation of the prostate and transurethral resection of the prostate (TURP) in men with lower urinary tract symptoms due to benign prostatic obstruction (BPO) has been questioned. OBJECTIVE: The primary objective of the GOLIATH study was to evaluate the noninferiority of 180-W GL XPS (XPS) to TURP for International Prostate Symptom Score (IPSS) and maximum flow rate (Qmax) at 6 mo and the proportion of patients who were complication free. DESIGN, SETTING, AND PARTICIPANTS: Prospective randomised controlled trial at 29 centres in 9 European countries involving 281 patients with BPO. INTERVENTION: 180-W GL XPS system or TURP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Measurements used were IPSS, Qmax, prostate volume (PV), postvoid residual (PVR) and complications, perioperative parameters, and reintervention rates. Noninferiority was evaluated using one-sided tests at the 2.5% level of significance. The statistical significance of other comparisons was assessed at the (two-sided) 5% level. RESULTS AND LIMITATIONS: The study demonstrated the noninferiority of XPS to TURP for IPSS, Qmax, and complication-free proportion. PV and PVR were comparable between groups. Time until stable health status, length of catheterisation, and length of hospital stay were superior with XPS (p<0.001). Early reintervention rate within 30 d was three times higher after TURP (p=0.025); however, the overall postoperative reintervention rates were not significantly different between treatment arms. A limitation was the short follow-up. CONCLUSIONS: XPS was shown to be noninferior (comparable) to TURP in terms of IPSS, Qmax, and proportion of patients free of complications. XPS results in a lower rate of early reinterventions but has a similar rate after 6 mo. TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT01218672.

Salvage treatment in prostate cancer: a clinical approach.

Radiotherapy is the main salvage option after primary radical prostatectomy. Radical prostatectomy, cryosurgical ablation and high-intensity focused ultrasound are the main salvage options after primary radiotherapy. After primary radiotherapy, long-term oncological outcome of salvage radical prostatectomy and salvage cryosurgical ablation is fairly comparable with the results of primary radical prostatectomy and primary cryosurgical ablation. Side effects of salvage radical prostatectomy in elite centers are acceptable and side effects of salvage cryosurgical ablation in tertiary centers are almost the same as after primary cryosurgical ablation. Good long-term data after salvage high-intensity focused ultrasound are lacking and the risk of side effects is considerable. After primary radical prostatectomy, there is a high level of evidence for oncological benefit of salvage radiotherapy. Careful patient selection is important for all salvage modalities.

Laparoscopic radical prostatectomy in men older than 70 years of age with localized prostate cancer: comparison of morbidity, reconvalescence, and short-term clinical outcomes between younger and older men.

OBJECTIVES: To analyze the safety and efficacy of extraperitoneal laparoscopic radical prostatectomy (eL-RPE) in elderly versus younger men with localized prostate cancer. METHODS: Patients undergoing eL-RPE were retrospectively subdivided into group eL-RPE1 (72 men aged 71 yr and older) and group eL-RPE2 (132 men aged 59 yr and younger). Group eL-RPE1 was compared with a group of 70 contemporary, comparable patients aged 71 yr and older undergoing open retropubic radical prostatectomy (group OPEN-RPE). RESULTS: Compared with group eL-RPE2, patients of group eL-RPE1 had a higher pathologic stage (45% vs. 32% stage pT3 or greater, p<0.001) and higher Gleason score (median 7 vs. 6, p<0.001). Prostate-specific antigen recurrence was significantly worse compared with age-matched controls for younger patients with high-stage or high-grade lesions (p<0.001). Importantly operative time, analgesic requirements, hospital stay, convalescence, and complication rates were comparable. Urinary continence rate was significantly better in group eL-RPE2 at 6 mo (67% vs. 91%, respectively, p<0.001). Group eL-RPE1 and group OPEN-RPE patients had statistically similar pathologic stage and Gleason score (each p>0.05), similar operative time (p=0.12), but less blood loss (p<0.001), shorter hospital stay (p<0.001), and more rapid convalescence (p<0.001) occurred in eL-RPE1. CONCLUSIONS: eL-RPE is feasible and efficacious even in elderly patients with unfavorable, large-volume disease. eL-RPE offers the advantages of decreased blood loss, shorter hospital stay, and more rapid recovery over OPEN-RPE. However, the elderly patient must be informed preoperatively about the observed higher incontinence rate.

Vesicourethral anastomosis during endoscopic extraperitoneal radical prostatectomy: a prospective comparison between the single-knot running and interrupted technique.

OBJECTIVES: To determine the safety and efficacy of the single-knot running versus interrupted technique for urethrovesical anastomosis during endoscopic extraperitoneal radical prostatectomy. METHODS: A total of 250 consecutive patients who underwent endoscopic extraperitoneal radical prostatectomy were prospectively divided into two groups of 125 patients each who underwent urethrovesical anastomosis using the single-knot running technique (group 1) or the interrupted suture technique (group 2). Surgical data, operative time, difficulty scores, extravasation rate, catheterization time, occurrence of anastomotic strictures, and the early and late continence rates were analyzed statistically. RESULTS: Regarding the clinical and pathologic findings, extravasation rate, catheterization time, and occurrence of anastomotic strictures, no significant differences were found between the two groups (P >0.05). The strongest independent predictors for extravasation were the integrity of the dorsal wall of the anastomosis and the degree of bladder neck opening (P <0.001). Overall, the continence rate at 3 and 6 months was 76% and 91.5% for group 1 and 77.6% and 93% for group 2, respectively (all P >0.05). The anastomosis technique had no impact on extravasation or continence status (all P >0.05). The only significant differences (P <0.001) in favor of the single-knot technique were the mean operative time and difficulty score (16 versus 24 minutes and 1 versus 3, respectively). CONCLUSIONS: Both techniques provide satisfactory and similar functional results. However, because of its simplicity and shorter operative time, the single-knot running technique appears preferable.

Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical Stage I nonseminomatous germ cell tumor: a comparison study.

OBJECTIVES: To compare the postoperative quality of life (QOL) and reconvalescence in patients with clinical Stage I nonseminomatous germ cell tumor (NSGCT) after laparoscopic retroperitoneal lymph node dissection (L-RPLND) and the open procedure (O-RPLND). METHODS: Twenty-one patients with NSGCT who underwent transperitoneal L-RPLND were matched and compared with 29 patients who underwent O-RPLND. The operative, QOL, and recovery data and complications and cure rates were analyzed for both groups. RESULTS: The mean follow-up time for the L-RPLND and O-RPLND groups was 14 months (range 6 to 20) and 26 months (range 8 to 38), respectively. No major complication requiring open surgical revision or prolongation of hospitalization was observed intraoperatively or postoperatively in either group. However, the early and late minor postoperative complications were significantly greater in the O-RPLND group than in the L-RPLND group (P <0.001). The L-RPLND patients had a significantly shorter hospitalization, greater QOL scores, and a faster return to normal activities than did the O-RPLND patients (all P <0.001). CONCLUSIONS: L-RPLND for patients with clinical Stage I NSGCT is a safe and efficacious procedure, with a faster reconvalescence and greater postoperative QOL than after O-RPLND.

Induction of spermatogenesis in men with azoospermia or severe oligoteratoasthenospermia after antegrade internal spermatic vein sclerotherapy for the treatment of varicocele.

AIM: To evaluate the treatment outcome of antegrade internal spermatic vein sclerotherapy in men with non-obstructive azoospermia or severe oligoteratoasthenospermia (OTA) as a result of varicocele. METHODS: Between September 1995 and January 2004, 47 patients (mean age 33.8 +/- 6.3 years) underwent antegrade internal spermatic vein sclerotherapy for the treatment of varicocele with azoospermia (14 patients) or severe OTA (33 patients). Testicular core biopsy was also performed in complete azoospermic patients who provided informed consent. The outcome was assessed in terms of improvement in semen parameters and conception rate. RESULTS: Forty-two (89.4%) of 47 patients had bilateral varicocele. Serum follicle stimulating hormone (FSH) did not differ between patients with azoospermia and severe OTA. After the follow-up of 24.8 +/- 9.2 months, significant improvement was noted in mean sperm concentration, motility and morphology in 35 patients (74.5%). Comparison between groups during the follow-up revealed significantly higher values of sperm concentration, motility and normal morphology in the severe OTA group. Pregnancy was achieved in 14 cases (29.8%). Testicular histopathology of the azoospermic patients with postoperative induction of spermatogenesis revealed maturation arrest at spermatid stage, Sertoli-cell-only (SCO) with focal spermatogenesis or hypospermatogenesis. None of the patients with pure SCO pattern or maturation arrest at spermatocyte stage achieved spermatogenesis after the treatment. Preoperative serum FSH levels didn't relate to treatment outcome. CONCLUSION: Antegrade internal spermatic vein sclerotherapy is an easy and effective treatment for symptomatic varicocele. It can significantly reverse testicular dysfunction and improve spermatogenesis in men with severe OTA, as well as induce sperm production in men with azoospermia, improving pregnancy rates in subfertile couples.

Extracorporeal shockwave therapy for Peyronie's disease: an alternative treatment?

AIM: To determine retrospectively the safety and efficacy of extracorporeal shock wave therapy (ESWT) in patients with Peyronie's disease. METHODS: Fifty-three patients with stable Peyronie's disease underwent ESWT (group 1). Fifteen patients matched with the baseline characteristic of the patients in group 1, who received no treatment, were used as the control (group 2). The patients' erectile function (International Index of Erectile Function [IIEF-5] score), pain severity (visual analog scale), plaque size and degree of penile angulation were assessed before and after the treatment in group 1 and during the follow-up in group 2. RESULTS: The mean follow-up time was 32 months (range: 6-64 months) in group 1 and 35 months (range: 9-48 months) in group 2. All the patients were available for the follow-up. Considering erectile function and plaque size, no significant changes (P > 0.05) were observed in group 1 before or after the ESWT. A total of 39 patients (74%) reported a significant effect in pain relief in group 1 after ESWT. However, regarding improvement in pain, IIEF-5 score and plaque size, no significant differences were observed between the two groups. In 21 patients (40%) of group 1, the deviation angle was decreased more than 10 degrees with a mean reduction in all patients of 11 degrees (range: 6-20 degrees). No serious complications were noted considering ESWT procedure. CONCLUSION: ESWT is a minimally invasive and safe alternative procedure for the treatment of Peyronie's disease. However, the effect of ESWT on penile pain, sexual function and plaque size remains questionable.

Intensive laparoscopic training: the impact of a simplified pelvic-trainer model for the urethrovesical anastomosis on the learning curve.

We prospectively evaluated the learning curve (LC) for laparoscopic urethrovesical anastomosis (L-UVA) in an operator-training model and program using an innovative simplified pelvic-trainer model. Over a period of 12 months, 30 LRP were performed by one urologist skilled in open surgery but inexperienced in laparoscopy. During the first 15 procedures no systematic training was done. Consequentially, a systematic simplified daily program was performed on the pelvic trainer with a videolaparoscopic unit. The training lesson consisted of intracorporal knotting and suturing, linear and circular interrupted suture anastomosis. At the end of each lesson, time and performance error scores were recorded and progression curve was plotted for each task. The performances of each training tasks were plotted against the performance of L-UVA during the LRP. The significance of progression was evaluated using logarithmic regression analysis. A steady improvement in time and accuracy of performance skill was shown during the first 20 lessons (p<0.001). These improved skill acquisitions were proportionally correlated with the time and the accuracy (water-tight) of L-UVA performance during the last 15 L-RPE. Compared to the first 15 L-RPE, where no systematic training was performed, time and accuracy of L-UVA performance in the last 15 L-RPE were improved from a mean 51 (median 48, range: 38-75) to 26 (median 24, range 18-33) min (p<0.001) and from 10 to 15 watertight anastomoses (p<0.001), respectively. Using a continuing, systematic, simplified training model the LC of L-UVA can be improved significantly in a short time.

Tension-free vaginal tape (TVT) in morbidly obese patients with severe urodynamic stress incontinence as last option treatment.

OBJECTIVES: To determine the safety and efficacy of tension-free vaginal tape (TVT) in morbidly obese women with severe urodynamic stress incontinence (USI) as last option treatment. METHODS: Thirty-one patients with body mass index (BMI) >40 kg/m2, who had undergone the TVT procedure for urodynamically-confirmed USI were matched with 52 patients with BMI <30 kg/m2 who underwent the same procedure. BMI was calculated at the time of the surgery. Patients' characteristics and surgical data, complications and cure rates were analyzed for both groups. RESULTS: After a mean follow-up of 18.5 (range: 12-24) months the continence rates were 87% and 92% for morbidly obese women and control group, respectively (p = 0.103). No serious intraoperative complications were noted in both groups. However, the early postoperative complications were significantly higher (p < 0.05) in morbidly obese patients. In 4 patients from both group long term postoperative catheterization was necessary for 4 weeks. In one patient (2%) from the control group dilatation of urethra took place. No defect in healing or rejection of the tape occurred. CONCLUSIONS: TVT is a minimal invasive and safe procedure for morbidly obese patients suffering from severe USI with good outcome. Preoperative morbid obesity does not seem to be a risk factor for failure of this procedure.

Laparoscopic radical prostatectomy using an extraperitoneal approach: Nordwest hospital technique and initial experience in 255 cases.

PURPOSE: We report on our modifications in technique and initial experience with 255 extraperitoneal laparoscopic radical prostatectomy (eLRP). PATIENTS AND METHODS: Using significant surgical modifications, our laparoscopic method replicates the steps of the retropubic descending RP. We evaluated 255 consecutive patients who underwent an eLRP with pelvic lymph-node dissection. RESULTS: The mean operative time was 136 minutes (range 84-266 minutes). Because of technical difficulty, the first three patients were converted to open surgery. One major complication, myocardial infarction, and one surgical reintervention in a case of secondary rectourethral fistula after open surgical repair of a laparoscopic rectal injury were observed. The blood transfusion rate was 1.2%. The pathologic stage was pT2a in 56 patients (22%), pT2b in 50 (20%), pT2c in 74 (29%), pT3a in 42 (16%), pT3b in 29 (11%), and pT4 in 3 (2%). Positive margins were found in 7% of patients (13/180) with pT2 tumors and 27% of patients (19/71) with pT3 tumors. The mean catheterization time was 7 days. The continence rates (no pads at all) at 3, 6, and 12 months were 73.7% (146/198), 89.6% (112/125), and 92.7% (38/41), respectively. After a nerve-sparing procedure, the total potency rates at 3 and 6 months were 37.5% (21/56) and 48.8% (21/43), respectively. CONCLUSION: The eLRP seems to be safe with short-term oncologic and functional results at least as favorable as those of open radical prostatectomy and classical transperitoneal LRP. The operative times are shorter, and the complication rate appears to be lower.

Erectile dysfunction after transurethral prostatectomy for lower urinary tract symptoms: results from a center with over 500 patients.

AIM: To identify possible risk factors for erectile dysfunction (ED) after transurethral resection of prostate (TURP) for benign prostatic hyperplasia (BPH). METHODS: Between March 1999 and March 2004, 629 patients underwent TURP in our department for the treatment of symptomatic BPH. All patients underwent transrectal ultrasound examination. In addition, the flow rate, urine residue, International Prostate Symptom Score (IPSS) and quality of life (QOL) were recorded for those who presented without a catheter. Finally, the erectile function of the patient was evaluated according to the International Index of Erectile Function Instrument (IIEF-5) questionnaire. It was determined that ED existed where there was a total score of less than 21. The flow rate, IPSS and QOL assessment were performed at 3 and 6 months post-treatment. The IIEF-5 assessment was repeated at a 6-month follow-up. A logistic regression analysis was used to identify potential risk factors for ED. RESULTS: At baseline, 522 (83%) patients answered the IIEF-5 questionnaire. The mean patient age was (63.7+/-9.7) years. The ED rate was 65%. After 6 months, 459 (88%) out of the 522 patients returned the IIEF questionnaire. The rest of the group was excluded from the statistical analysis. Six months after TURP, the rate of patients reporting ED increased to 77%. Statistical analysis revealed that the only important factors associated with newly reported ED after TURP were diabetes mellitus (P = 0.003, r = 3.67) and observed intraoperative capsular perforation (P = 0.02, r = 1.12). CONCLUSION: The incidence of postoperative, newly reported ED after TURP was 12%. Risk factors for its occurrence were diabetes mellitus and intraoperative capsular perforation.

Retroperitoneoscopic versus open surgical radical nephrectomy for large renal cell carcinoma in clinical stage cT2 or cT3a: quality of life, pain and reconvalescence.

OBJECTIVES: To determine whether retroperitoneoscopic radical nephrectomy for large renal cell carcinoma in stage cT2 or cT3a is a feasible, safe and effective therapy option and if it shows any advantage regarding quality of life in comparison to open procedure. METHODS: 23 patients who underwent RPNx for tumor size greater than 7 cm (group 1) were matched and compared with 25 patients, who underwent ONx (group 2) for tumor with similar size characteristics. Patient and surgical data, QoL variables and complications were statistically analyzed. RESULTS: The median followup was 12 (range: 6-18) months for both groups. Group 1 had significantly (p < 0.001) less blood loss, shorter hospital stay, and shorter postoperative analgesic requirements. No conversion to open surgery was necessary, and no major complications requiring an invasive intervention occurred. Retroperitoneoscopic patients had significantly better QoL and pain scores postoperatively to 6 months (p < 0.001) and they return to baseline QoL status faster (p < 0.001). CONCLUSIONS: RPNx for large RCC in stage cT2 or cT3a is a safe and efficacious procedure with good short-term outcome results and significantly shorter recovery of QoL variables.

Laparoscopic radical prostatectomy: the value of intraoperative frozen sections.

OBJECTIVE: To examine the clinical and pathological value of intraoperative frozen section (IFS) in patients undergoing laparoscopic radical prostatectomy (L-RPE) for clinically localized prostate cancer. METHODS: The study includes 198 consecutive cases of L-RPE. After removal of the prostate, a 2-3mm circumferential specimen was obtained from the apical and bladder neck soft-tissue margin and submitted for IFS examination. In cases suspicious for capsular incision (n=57), IFS were taken from the neurovascular bundle/lateral pedicle. RESULTS: The IFS diagnosis from the apical, bladder neck, and neurovascular bundle/lateral pedicle soft-tissue margins was adenocarcinoma in 12 (6%), 1 (0.5%), and 2 (1%) cases, respectively. Patient age, clinical stage, and mean specimen weight were not associated with cancer at the apical IFS. The accuracy, sensitivity, specificity, positive and negative predictive value of the apical IFS to predict cancer in the permanent section of the apical soft-tissue margin was 96%, 70%, 97%, 58%, and 98%, respectively. All the patients (n=15) with cancer at IFS had wide resections of additional tissue in the area of positive soft-tissue margin and all had no cancer in the additional resected tissue. Especially at the apex, IFS decreases the overall PSM status on surgical specimen by 5.1% (apical PSM from 8.6% to 3.5%). CONCLUSION: Because of the low predictive value of IFS of bladder neck and neurovascular bundle/lateral pedicle their use is not recommended. IFS of the apex should be performed to reduce the PSM rate.

Laparoscopic radical prostatectomy: prospective evaluation of the learning curve.

OBJECTIVE: We prospectively evaluated the learning curve (LC) of laparoscopic radical prostatectomy (L-RPE) regarding the improvements in operative times (OT) and technical difficulty in one-operator-practice as it compares with open RPE. METHODS: Over 18 months, 50 L-RPE were performed by an inexperienced surgeon in laparoscopy but skilled in open surgery. Difficulty scores were obtained at the completion of each L-RPE comparing L-RPE to open RPE. OT, estimated blood loss (EBL), length of stay, and catheterization time were also obtained. RESULTS: In the ablative part of L-RPE the median difficulty score was significantly higher (p<0.001) for the first 10 cases, decreased dramatically by case 11 becoming equivalent (p=0.3) to open RPE and by case 31 the L-RPE becomes significantly easier than open RPE (p=0.002). The difficulty scores for the urethrovesical anastomosis performance is always uniformly higher for the whole patient series (p<0.001). Median OT decreased significantly from 293 minutes in the first 10 cases to 114 minutes in the last 10 cases (p<0.001). Catheterization time and length of hospitalization, decreased significantly with the progression of the LC. EBL remained stable throughout the patient cases. Obesity, prior surgery, and extension of the procedure (lymphadenectomy, nerve-sparing) significantly increased the OT. CONCLUSION: Although the ablative part of L-RPE has a relatively short LC for a skilled open surgeon reflected by the rapid decrease in difficulty scores and OT by case 21, the performance of anastomosis shows a longer LC. Intensive training on anastomosis may be necessary to master this skill.