Patients Regret Their Choice of Therapy Significantly Less Frequently after Robot-Assisted Radical Prostatectomy as Opposed to Open Radical Prostatectomy: Patient-Reported Results of the Multicenter Cross-Sectional IMPROVE Study.

Patient's regret (PatR) concerning the choice of therapy represents a crucial endpoint for treatment evaluation after radical prostatectomy (RP) for prostate cancer (PCA). This study aims to compare PatR following robot-assisted (RARP) and open surgical approach (ORP). A survey comprising perioperative-functional criteria was sent to 1000 patients in 20 German centers at a median of 15 months after RP. Surgery-related items were collected from participating centers. To calculate PatR differences between approaches, a multivariate regressive base model (MVBM) was established incorporating surgical approach and demographic, center-specific, and tumor-specific criteria not primarily affected by surgical approach. An extended model (MVEM) was further adjusted by variables potentially affected by surgical approach. PatR was based on five validated questions ranging 0−100 (cutoff >15 defined as critical PatR). The response rate was 75.0%. After exclusion of patients with laparoscopic RP or stage M1b/c, the study cohort comprised 277/365 ORP/RARP patients. ORP/RARP patients had a median PatR of 15/10 (p < 0.001) and 46.2%/28.1% had a PatR >15, respectively (p < 0.001). Based on the MVBM, RARP patients showed PatR >15 relative 46.8% less frequently (p < 0.001). Consensual decision making regarding surgical approach independently reduced PatR. With the MVEM, the independent impact of both surgical approach and of consensual decision making was confirmed. This study involving centers of different care levels showed significantly lower PatR following RARP.

Shoulder Strength and Closed Kinetic Chain Upper Extremity Stability Test Performance in Division III Collegiate Baseball and Softball Players.

BACKGROUND: Shoulder strength measured with a handheld dynamometer (HHD) and the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) are clinical tools that have been used to measure athlete's performance and track their progress. PURPOSE: The specific aims of this study were to describe baseball (BB) and softball (SB) players isometric strength measures and their performance on the CKCUEST; examine the relationships between strength and the CKCUEST; compare isometric strength measures of the throwing and non-throwing arms; and compare the strength and the CKCUEST measures between BB and SB players. STUDY DESIGN: Observational cohort study. METHODS: Participants included 50 DIII BB and 24 DIII SB players. Shoulder strength for the internal and external rotators were measured using a HHD and the CKCUEST was performed. The CKCUEST score and power were calculated. Descriptive statistics and paired t-tests were used to compare throwing and non-throwing shoulder strength. Independent t-test was used to compare BB and SB players shoulder strength and the CKCUEST measures. RESULTS: The BB players demonstrated significant strength differences between the throwing and non-throwing shoulders and the internal rotators were significantly stronger than the external rotators (p < 0.05), while the strength ratio of the internal and external rotators was not different between arms (p=0.87). The SB players demonstrated no significant strength differences between the throwing and non-throwing shoulders for the internal and external rotators or the strength ratio of the rotators (p > 0.05). There were no significant differences between the strength of the internal and external rotators of the non-throwing shoulder (p=0.075) or the throwing shoulder (p=0.096). The BB players throwing and non-throwing shoulders produced significantly more internal and external force than the SB players (p < 0.001), however, the internal/external rotators strength ratio were similar (p=0.32, p=0.30). The CKCUEST power had inverse and significant correlations (p=0.006, p=0.003) with SB players internal and external rotators, respectively. The CKCUEST power was significantly different between BB and SB players (p < 0.001). CONCLUSION: This study presented shoulder rotator strength and CKCUEST reference values for DIII BB and SB players. BB players demonstrated more strength but overall, less symmetry compared to SB players. CKCUEST power may be considered for the evaluation of athletes. LEVEL OF EVIDENCE: Level III.

Experience Of Resident Presentations In Consultation-Liaison Psychiatry Grand Rounds: Increase Value For Clinical Education.

BACKGROUND: Grand rounds is a formal meeting at which physicians and trainees discuss excellence in medical care. Residents should participate in scholarly activity per Accreditation Council for Graduate Medical Education (ACGME). Consultation-Liaison (CL) psychiatry focuses on caring for patients presenting with psychiatric complications in general hospital. Post-residency subspecialty CL fellowship training plays a big role in creating future leaders in CL. Our program decided to conduct annual CL grand rounds fully allotted to discuss complex CL psychiatry cases in medical setting. METHODS: We conducted a retrospective review of resident's interest in pursuing CL fellowship. We compared the number of residents pursuing CL fellowship after the CL grand rounds to the previous years starting 2005 when CL was recognized as an ACGME approved subspecialty. We also compared our program residents pursuing CL psychiatry fellowship to national trend obtained from National Residency Matching Program (NRMP). RESULTS: From 2013 to 2018, CL grand rounds n=8, Number of residents graduated from 2013 to 2018 n=26. Number of residents pursued CL fellowship from 2013 to 2018 n=3 (11.5%) compared to no residents pursuing CL fellowship before 2013. Fisher's exact test to compare and examine the data from the residents pursuing CL fellowship after implementation of the CL grand rounds is 0.0668 (p value < 0.10). When combining all the available NRMP match results for CL from 2015 to 2019, a total of 531 positions were offered and 359 positions were filled (fill rate of 67.6%). In our program, after we implemented the annual CL grand rounds, 11.5% of the residents from 2013 to 2018 pursued CL fellowship, which is higher than the likely national average of 5.7%. CONCLUSION: Our residency program grand rounds educational module appears to nurture and sustain interest in CL subspecialty compared to previous years. Prospective studies are required.

SHOULDER RANGE OF MOTION CHARACTERISTICS IN DIVISION III COLLEGIATE SOFTBALL AND BASEBALL PLAYERS.

BACKGROUND: Adaptive changes may occur to the throwing shoulder of overhead athletes that can influence range-of-motion (ROM). Shoulder ROM characteristics of Division III softball (SB) and baseball (BB) players are unique. HYPOTHESIS/PURPOSE: To report the passive ROM characteristics of Division III SB and BB players and identify similarities and differences between these two populations. STUDY DESIGN: Descriptive, observational research on measurement. METHODS: Participants included healthy Division III BB (n = 50) and SB (n = 24) players. Passive shoulder internal rotation (IR) and external rotation (ER) ROM were measured in the supine position with the arm in 90 ° of abduction and the scapula stabilized. Descriptive statistics and frequency distributions were used to describe ROM. Paired and independent t-tests were also used to compare throwing and non-throwing shoulder ROM for athletes of each sport and to compare the shoulder ROM of SB and BB players, respectively. RESULTS: The IR and ER ROM for BB players throwing shoulders (IR 54.1 ± 10.9 °; ER 94.1 ± 9.1 °) were significantly different (p < 0.001) from their non-throwing shoulders (IR 63.3 ± 11.1 °; ER 87.6 ± 9.2 °) while SB players were not (p = .06 & .08, respectively). Compared to the BB players, the throwing shoulder of SB players demonstrated statistically significantly higher IR ROM (p < .001, mean difference = 11.8 °, 95% CI: 6.4-17.2 °) as well as higher total range of motion (TRM) (p < .001, mean difference = 14.4 °, 95% CI: 8.6-20.2 °) when compared to BB players. Glenohumeral internal rotation deficit (GIRD) was significantly higher in BB players when compared to SB players (p = .042, 95% CI: .2-10.8 °). There were no significant differences in IR, ER, TRM, GIRD and ER gain between SB or BB pitchers and all other field positions (p > .05). CONCLUSIONS: SB players have more ROM and bilateral symmetry when compared to BB players. TRMD occurred more often than GIRD in BB players, indicating that they did not adaptively gain the same amount of ER while losing IR. The throwing shoulder ROM characteristics of both SB and BB players in this study were not influenced by the player's position (pitcher vs. field player). LEVEL OF EVIDENCE: Level III.

Using the Clerkship Shelf Exam Score as a Qualification for an Overall Clerkship Grade of Honors: A Valid Practice or Unfair to Students?

Most clerkships require medical students to pass the National Board of Medical Examiners (NBME) subject (shelf) exam to pass the clerkship. Many use the NBME's recommended honors cut score on the shelf exam to determine medical student eligibility for an overall clerkship grade of honors. This use of a conjunctive scoring model for determining honors is inconsistent with the logic behind the intended use of this model for making pass-fail determinations. Further, many clerkships use grading systems that employ both this conjunctive model for honors eligibility and a compensatory scoring model for determining the overall clerkship grade. For students who fall short of the shelf exam honors cut score, such a grading system effectively increases the weighting of shelf exam performance and decreases the clerkship's transparency about the weighting of performance on other assessments toward the clerkship composite score and overall grade. It may also lead to contradictory grading results in which student B has a higher composite score than student A, yet student B receives a lower overall grade. The author illustrates how to calculate a weight for shelf exam performance that would be fairer to students and would help create a more transparent weighting scheme for the grading system. The author recommends that clerkships restructure their grading systems so that shelf exam honors-eligibility cut scores are not used as conjunctive criteria for determining overall clerkship grades of honors. A reexamination of the NBME's practice of suggesting honors-eligibility cut scores for shelf exams is also recommended.

[Pressure study of two miniaturised amplatz sheaths of 9.5 F and 12 F outer diameter for minimal invasive percutaneous nephrolithotomy (MIP): An ex vivo organ model measurement]. / Druckverhältnisse bei Verwendung miniaturisierter PNL-Schäfte mit 9,5 Ch bzw. 12 Ch Außendurchmesser für die minimalinvasive perkutane Nephrolitholapaxie (MIP): Ex-vivo-Druckstudien.

Over the last decade, several devices for percutaneous nephrolithotomy with smaller diameters have been introduced in order to reduce renal trauma. Recent studies have found comparable stone free rates but also exhibit the same rate of postoperative fever and septicaemia. One possible cause is the influence of irrigation fluid during stone treatment procedures. The purpose of this ex vivo study was to compare two new miniaturised PNL nephroscopy sheaths with an outer sheath diameter of 9.5 F and 12 F to the well-established MIP M Set (17.5 F) by Karl Storz. MATERIAL AND METHODS: The new devices were tested in a perfused organ model of fresh porcine kidneys with different irrigation pressures, applied either by gravitation or the use of a pressure pump (Uromat E.A.S.I. Pump, Karl Storz, Tuttlingen, Germany).In addition, the 9.5 F sheath was examined for active irrigation evacuation, i. e. suction of irrigation fluid through a mono-J-catheter. An urodynamic pressure probe measured intrapelvic pressure levels throughout the procedures. RESULTS: Regardless of the sheath diameters used, the intrapelvic pressure did not exceed 40 cmH2O (30 mmHg) when applying moderate irrigation pressure levels, either by pump or gravitation. The active suction of irrigation fluid from the kidney basin via the mono-J-catheter had no measurable impact on the detected intrarenal pressures. A crucial increase in the intrapelvic pressure was detected only when using the 9.5 F sheath in combination with applying high irrigation pressures. CONCLUSION: The newly designed miniaturised MIP sets maintain the favourable pressure features of the earlier 17.5 MIP sheath. Although the diameter has been reduced to 12F or 9.5 F, the intrapelvic pressures remained below 40 cmH2O when regular irrigation settings by gravitation or pump irrigation were used.

Review of mini-clinical evaluation exercise (mini-CEX) in a psychiatry clerkship.

BACKGROUND: Direct observation of medical students with actual patients is important for the assessment of clinical skills including interviewing and counseling skills. This article describes medical students' experience of mini-clinical evaluation exercise (mini-CEX) during their clerkship in consultation psychiatry. MATERIALS AND METHODS: In our center during inpatient consultation psychiatry clerkship, all rotating students are expected to complete one mini-CEX assessment as part of their clinical training. We conducted retrospective analysis of mini-CEX ratings completed from 2013 to 2016. All evaluations took place at inpatient medical setting in patients admitted with medical conditions and psychiatric comorbidities. RESULTS: A total of 113 evaluations were reviewed. The time examiner observed the interaction of a student with the patient was 14.24 minutes (mean), and the time spent in providing feedback to the student was 9.71 minutes. Complexity of problem was rated as low in 0.88% (n=1), moderate in 50.44% (n=57), and high in 48.67% (n=55). Highest ratings were for professionalism, similar to previous reports. Total score calculated by examiner showed no difference by the complexity of the patient; however, we observed a trend in higher counseling score for the high complexity group. CONCLUSION: Mini-CEX assessment during busy clerkship is feasible with good outcomes. Direct observation of medical trainees with actual patients is important for the assessment of performance-based clinical skills. Hospital psychiatry rotation covering various medical and surgical units offers a great opportunity for exposure in patient communication.

The Value and Evaluability of the PCA3 Urine Assay in Prostate Carcinoma is Independent of the Tumor Localization.

INTRODUCTION: The prostate cancer gene 3 (PCA3) test is based on the analysis of tumor cell mRNA in urine. As an exprimated urinary marker, its retrieval is subject to certain physical aspects like palpation pressure and detachment force during the squeezing of cells. Other potential factor of influence may be the distance the cells have to cover until they reach the urethra. Thus, it was investigated whether the localization of the tumors within the prostate with regard to the urethra and the seminal colliculus influences the PCA3 score. METHODS: Prostatectomy specimens of 55 organ-confined prostate cancer patients were processed according to the Stanford protocol. For each prostatectomy specimen, a three-dimensional reconstruction including the surface of the prostate, the tumor areas and the urethra was created. By model simulating, virtual concentric tubes were placed around the urethra and spherical volumes were virtually positioned around the seminal colliculus at diameters of 8, 16 and 32 mm. Depending on localization, tumor volumes may or may not protrude into the tubes or spherical volumes. For each respective diameter, PCA3 levels were compared between the subgroup with and without protrusion of tumor tissue into the tube or spherical ball. RESULTS: For none of the diameters, whether in tubes or spherical balls, were patients without intersection volumes-hence showing peripherally located tumors-found to have lower PCA3 levels. No clinical or histopathological parameter correlated with the PCA3 score. CONCLUSION: The location of the tumor mass in the prostate with respect to the urethra or the seminal colliculus did not to affect the PCA3 score. Hence, the location of the tumor does not limit the validity of the PCA3 score, and even for exclusively peripherall y located tumors, this possible influencing factor did not lead to an artificial modulation of the PCA3 score.

Strategy of robotic surgeons to exert public influence through Twitter.

BACKGROUND: Twitter is gaining growing popularity as a communication platform and potential tool to influence the public in medical matters. The aim here is to examine whether and how robotic surgeons use Twitter more influentially than other urologists. METHODS: Robotic surgeons and other urologists that tweeted at the European urology congress were compared by assessing Twitter Follower/Following Ratio, Retweet Rank and Percentile and their Twitter strategies. RESULTS: Robotic surgeons had a significantly higher Twitter Follower/Following Ratio (2.1, 1.4-2.4) and Retweet Rank percentile (92.1%, 90.5-93%) than other urologists (1.2, 0.8-2.1 and 88.9%, 87.3-91.7%, respectively). Robotic surgeons used original tweet content and links more often than other urologists (69.4% vs 53.8%, and 19.8% vs 12.5%, respectively). CONCLUSIONS: Robotic surgeons had a higher public influence on Twitter than other urologists and posted original tweets and links in tweets and profiles more frequently. This strategy might optimize Twitter use by healthcare professionals in the future. Copyright © 2016 John Wiley & Sons, Ltd.

Minimally invasive versus conventional large-bore percutaneous nephrolithotomy in the treatment of large-sized renal calculi: Surgeon's preference?

OBJECTIVE: The aim of this study was to compare the efficacy and safety of minimally invasive percutaneous nephrolithotomy (MIP) and conventional percutaneous nephrolithotomy (PCNL) in the treatment of patients with large renal stone burden. MIP has proven its efficacy and safety in the management of small renal calculi. However, conventional PCNL is still considered the standard method for treatment of large renal stones in the upper urinary tract. MATERIALS AND METHODS: A search of two longitudinal databases in two tertiary referral centres for complex stone disease identified 133 consecutive patients who were treated by either MIP or PCNL for renal stones 20 mm or larger between January 2009 and August 2012. Clinical data and outcome measures of the two methods were compared by Student's t test, chi-squared test or Fisher's exact test. A p value less than 0.05 was considered statistically significant. RESULTS: Operative time was significantly shorter and hospital stay was significantly longer in conventional PCNL compared to MIP (p = 0.002 and < 0.001, respectively). There were no significant differences in primary stone-free rate or complication rate between the two methods. Only higher graded complications (above Clavien grade II) were significantly more common in conventional PCNL (p = 0.02). CONCLUSION: MIP is equally effective as conventional PCNL in the treatment of large renal calculi. Both methods have a similar complication rate. The shorter operative time in PCNL may be based on the larger diameter and quicker retrieval of large fragments; the longer mean hospital stay may be caused by the handling of the nephrostomy tube. The current data suggest that the choice of the method mainly depends on the surgeon's preference.

Nodal Clearance Rate and Long-Term Efficacy of Individualized Sentinel Node-Based Pelvic Intensity Modulated Radiation Therapy for High-Risk Prostate Cancer.

PURPOSE: To assess the efficacy of individual sentinel node (SN)-guided pelvic intensity modulated radiation therapy (IMRT) by determining nodal clearance rate [(n expected nodal involvement - n observed regional recurrences)/n expected nodal involvement] in comparison with surgically staged patients. METHODS AND MATERIALS: Data on 475 high-risk prostate cancer patients were examined. Sixty-one consecutive patients received pelvic SN-based IMRT (5 × 1.8 Gy/wk to 50.4 Gy [pelvic nodes + individual SN] and an integrated boost with 5 × 2.0 Gy/wk to 70.0 Gy to prostate + [base of] seminal vesicles) and neo-/adjuvant long-term androgen deprivation therapy; 414 patients after SN-pelvic lymph node dissection were used to calculate the expected nodal involvement rate for the radiation therapy sample. Biochemical control and overall survival were estimated for the SN-IMRT patients using the Kaplan-Meier method. The expected frequency of nodal involvement in the radiation therapy group was estimated by imputing frequencies of node-positive patients in the surgical sample to the pattern of Gleason, prostate-specific antigen, and T category in the radiation therapy sample. RESULTS: After a median follow-up of 61 months, 5-year OS after SN-guided IMRT reached 84.4%. Biochemical control according to the Phoenix definition was 73.8%. The nodal clearance rate of SN-IMRT reached 94%. Retrospective follow-up evaluation is the main limitation. CONCLUSIONS: Radiation treatment of pelvic nodes individualized by inclusion of SNs is an effective regional treatment modality in high-risk prostate cancer patients. The pattern of relapse indicates that the SN-based target volume concept correctly covers individual pelvic nodes. Thus, this SN-based approach justifies further evaluation, including current dose-escalation strategies to the prostate in a larger prospective series.

Clearance of Stone Fragments and Stone Dust by Continuous Flow Hydrodynamics in Percutaneous Renal Surgery: An In Vitro Study.

PURPOSE: To investigate the capacity of stone clearance in common percutaneous nephrolithotomy (PCNL) systems achieved solely by hydrodynamic effects in an in vitro setting. METHODS: A watertight cylindrical cast with a caliceal void served as an in vitro model. Various instruments for percutaneous renal surgery working with both continuous flow (fCF) and open Rutner sidearm (fCO) were tested. The model was loaded with standardized artificial stone material (2 mm in diameter) to examine stone removal by the vacuum cleaner effect and with sand (0.1-0.5 mm in diameter) to measure the washout effect caused by irrigation backflow. The association between washout of gravel and irrigation pressure was analyzed using ANOVA. Regression analysis was performed to assess the influence of the instruments' hydrodynamic characteristics-effective cross section of the outflow and irrigation flow volume. RESULTS: Provoking the vacuum cleaner effect removal of stones was only effective in fCF but not in fCO instruments. Depending on irrigation pressure, the volumetric flow rate and effective cross section of the outflow clearance of sand could be observed in various medium- and large-sized fCF and fCO instruments, whereas in small-sized systems, clearance effects were negligible. Regression analysis showed clearance of stone dust strongly associated with an instrument's volumetric flow rate. CONCLUSIONS: This in vitro study demonstrated that the application of medium- and large-sized fCF PCNL systems removes both "insignificant" stones and dust solely by hydrodynamic effects. Further studies have to show if these effects also occur in the in vivo situation.

Evaluation of the 'Prostate Interdisciplinary Communication and Mapping Algorithm for Biopsy and Pathology' (PIC-MABP).

INTRODUCTION: Experience from interdisciplinary cooperation revealed the need for a prostate mapping scheme to communicate multiparametric MRI (mpMRI) findings between radiologists, urologists, and pathologists, which should be detailed, yet easy to memorize. For this purpose, the 'Prostate interdisciplinary communication and mapping algorithm for biopsy and pathology' (PIC-MABP) was developed. This study evaluated the accuracy of the PIC-MABP system. METHODS: PIC-MABP was tested and validated in findings of 10 randomly selected patients from routine clinical practise with 18 histologically proven cancer lesions. Patients received an mpMRI of the prostate prior to prostatectomy. After surgery the prostates were prepared as whole-mount step sections. Cancer lesions, which were found suspicious on mpMRI, were assigned to the according PIC-MABP sectors by a radiologist. MpMRI slides were masked and sent to seven urologists from different centres, providing only the PIC-MABP location of each lesion. Urologists marked the accordant regions. Then mpMRI slides were unmasked, and the correctness of each mark was evaluated. RESULTS: One hundred and seventeen of the 126 marks (93%) were correctly assigned. Detection rates differed for lesions >0.5 cc compared with lesions <0.5 cc (p < 0.005): 3/7 (43%) marks were correctly assigned in lesions <0.3 cc, 16/21 (76%) in lesions with 0.3-0.5 cc, and 98/98 (100%) in lesions >0.5 cc. Interobserver agreement was good for lesions >0.5 cc and poor for lesions <0.3 cc (Fleiss Kappa 1 vs. 0.0175). CONCLUSION: PIC-MABP seems to be a reliable system to communicate the location of mpMRI findings >0.5 cc between different disciplines and can be a useful guidance for cognitive mpMRI/TRUS fusion biopsy.

Utilization of surgical safety checklists by urological surgeons in Germany: a nationwide prospective survey.

OBJECTIVES: We aimed to investigate the contemporary usage rate and habits of the WHO Surgical Safety Checklist (SSC) in German urological departments. METHODS: We designed a 26-item questionnaire that was sent to all urological departments in Germany. The primary aim of this study was to evaluate the usage rate of the SSC. Secondary aims were to compare perioperative characteristics of users vs. non-users of the SSC and to assess circumstances of the SSC application. RESULTS: A total of 213 of 234 (91 %) urological departments were users of the SSC, and 21 (9 %) were non-users. SSC users had more often a standard protocol, took less time and had fewer people involved for checking perioperative patient data compared to non-users. Financial budgeting for the SSC existed in 55 (24 %) departments and for patient safety in 73 (32 %) departments. CONCLUSIONS: The usage rate of the SSC in urological departments in Germany is high despite restricted financial budgeting. Users of the SSC profit by saving time and manpower for checking perioperative patient data.

Risk and timing of biochemical recurrence in pT3aN0/Nx prostate cancer with positive surgical margin - A multicenter study.

BACKGROUND AND PURPOSE: Positive surgical margins (PSM) after radical prostatectomy have been shown to be associated with impaired outcome. In pT3pN0 patients with PSM either immediate radiotherapy or clinical and biological monitoring followed by salvage radiotherapy is recommended by the latest guidelines of the European Association of Urology. MATERIALS AND METHODS: A retrospective, multicenter study of eight urological centers was conducted on 536 prostatectomy patients with pT3aN0/NxR1 tumors and no neoadjuvant/adjuvant therapy. A pathological re-review of all prostate specimens was performed. Association of clinical and pathological features with biochemical recurrence (BCR) was analyzed using univariate and multivariate analysis. RESULTS: With 48months median follow-up, BCR occurred in 39.7%. Preoperative PSA value, performance of pelvic lymph node dissection and Gleason score were significantly associated with BCR. In multivariate analysis, Gleason score was the only independent prognostic factor (p<0.001) for BCR. Five-year BCR-free survival rates were 74%, 70%, 38%, and 51% with Gleason score 6, 3+4=7a, 4+3=7b, and 8-10, respectively. CONCLUSIONS: In pT3aN0/NxR1 patients with no adjuvant/neoadjuvant treatment, Gleason Score permits independent prediction of the risk for BCR. These findings could help to estimate and discuss the individual risk for BCR with our patients on an individual basis.

Feasibility, complications and oncologic results of a limited inguinal lymph node dissection in the management of penile cancer.

PURPOSE: In patients with penile cancer (PeCa) and increased risk of inguinal lymphatic dissemination, inguinal lymphadenectomy offers a direct histological staging as the most reliable tool for assessment of the nodal metastasic status and a definitive oncologic treatment simultaneously. However, peri- and/or postoperative mutilating sequalae often occurn. We report on clinical outcome and complications of a limited inguinal lymph node (LN) dissection. MATERIALS AND METHODS: Clinical and histopathological data of all patients with PeCa who underwent limited inguinal lymphadenectomy (LIL) at our institution between 1986 and 2012 were comprehensively analyzed. Perioperative results were presented in relation to one-sided procedures, if appropriate, which were assessed without cross comparison with contralateral LILs. RESULTS: 29 consecutive patients with PeCa aged 60±10.3 years were included in the current study with 57 one-sided LIL performed. Mean operative time for one-sided LIL was 89.0±37.3 minutes with 8.1±3.7 LNs removed. A complication rate of 54.4% (n=31), including 16 minor and 15 major complications was found in a total of 57 procedures with leg oedema being the most prevalent morbidity (15.8%). 4 patients with clinically positive LNs developed inguinal lymphatic recurrence within 9 months after surgery. CONCLUSIONS: Our technique of limited inguinal LN dissection provided an acceptable complication rate without aggravating morbidity. We experienced no recurrences in clinically LN negative patients, so that the approach might be a reasonable option in this scenario. In patients with enlarged LNs, radical inguinal lymphadenectomy still appears to represent the gold standard.

Feasibility, complications and oncologic results of a limited inguinal lymph node dissection in the management of penile cancer

In patients with penile cancer (PeCa) and increased risk of inguinal lymphatic dissemination, inguinal lymphadenectomy offers a direct histological staging as the most reliable tool for assessment of the nodal metastasic status and a definitive oncologic treatment simultaneously. However, peri- and/or postoperative mutilating sequalae often occurn. We report on clinical outcome and complications of a limited inguinal lymph node (LN) dissection.

The vacuum cleaner effect in minimally invasive percutaneous nephrolitholapaxy.

INTRODUCTION: Percutaneous stone removal increasingly plays an important role among the different approaches of interventional stone therapy, particularly since the development of miniaturized instruments is resulting in lower morbidity for the patients. One major drawback of smaller instruments is the increased difficulty of stone retrieval after disintegration due to the reduced tract diameter. This results in longer operation time and the need of additional tools such as disposable retrieval baskets. One of the key factors in the development of minimally invasive percutaneous nephrolitholapaxy (MIP) was the design of an Amplatz sheath which provides a built-in vacuum cleaner effect for stone retrieval. METHODS: A series of flow analyses with the gauges and shapes of the most commonly used nephroscopes and sheaths in percutaneous nephrolitholapaxy was performed by computational fluid dynamics. Flow velocity and direction in front of the nephroscope were computed and visualized by the software. RESULTS: In our study, the vacuum cleaner effect developed exclusively when a round-shaped nephroscope was used (Nagele Miniature Nephroscope System, Karl Storz GmbH & Co. KG) and depended on the relation between nephroscope diameter and inner sheath diameter. The strongest effect was observed with a 12 F nephroscope and an inner sheath diameter of 15 F. It did not develop when an oval- or crescent-shaped nephroscope was used. In front of the distal end of the round-shaped nephroscope, a slipstream develops, induced by the excursive change of width of the fluid flow on the outlet of the flushing canal. This allows the adhesion of a stone fragment in the eddy while the fluid flow is circulating around the stone. CONCLUSION: This study illustrates and explains the vacuum cleaner effect which has been detected in the development of the Nagele Miniature Nephroscope System used in MIP. It combines the reduced morbidity of smaller kidney puncture diameters with the benefit of quick and complete stone removal.