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.

[Implementation of Enhanced Recovery after Surgery (ERAS®) protocol in radical cystectomy at the University Medical Center Mainz]. / Implementierung des ERAS®-Protokolls (Enhanced Recovery After Surgery) nach radikaler Zystektomie an der Universitätsmedizin Mainz.

BACKGROUND: In surgical fields there has been a perceivable paradigm shift during the last decade concerning patient pre- and rehabilitation. Current literature suggests close interdisciplinary collaboration after complex procedures such as radical cystectomy in order to optimize perioperative patient care for the benefit of "fast-track" surgery. OBJECTIVES: To compose a catalogue of standardized measures after radical cystectomy based on guidelines set by the ERAS®-Society. RESULTS: The protocol commences with preoperative education in order to improve the physical and psychological condition of the patient. Crucial aspects in peri- and postoperative patient care are gentle surgical technique, adequate pain management, early mobilization and oral food intake, early removal of drains and foreign material and a seamless return to normal, daily life. CONCLUSIONS: Prospective data analysis will be the next step in order to establish the effectiveness of the protocol especially regarding postoperative complications and median duration of hospital stay.

Immunohistochemical detection of 1,25-dihydroxyvitamin D3 receptors (VDR) in human skin. A comparison of five antibodies.

Increasing evidence suggests an important regulatory function for 1 alpha,25-dihydroxyvitamin D3 in the growth control of epidermal cells and in skin immunology. Using immunohistochemical techniques we investigated the in situ expression of 1,25-dihydroxyvitamin D3 receptors (VDR) in normal human skin with one monoclonal rat antibody and four monospecific polyclonal rat antibodies to the VDR. Polyclonal rabbit antibodies have been raised against synthetic peptides corresponding to different amino acid residues of the human VDR, including regions close to the DNA binding domain and the hormone-binding domain. All antibodies revealed positive immunoreactivity in normal human skin. The antibodies showed differences in subcellular immunoreactivity and staining-intensity. Differences in subcellular distribution of VDR immunoreactivity are caused by the different epitopes recognized by the antibodies and not by the affinity of the antibodies for VDR. It seems that the antibodies may recognize different functional modifications of the receptor molecule (i.e.: hormone bound vs. hormone free; DNA bound vs. non-DNA bound; VDR vs. VDR/retinoid-X receptor [RXR] heterodimers). Using these newly raised antibodies future studies will be carried out to analyse subcellular distribution of VDR immunoreactivity in skin pathology.

Immunohistochemical detection of retinoic acid receptor alpha in human skin: a comparison of different fixation protocols.

A technique for the immunohistochemical detection of retinoic acid receptor alpha in cryostat sections of normal human skin in situ has been developed. A highly specific mouse monoclonal antibody, directed against the F region of retinoic acid receptor alpha, was used and a panel of 10 fixation protocols investigated. A three-step protocol, consisting of sequential fixation in 3.7% paraformaldehyde, methanol and acetone, revealed strong nuclear immunoreactivity in epidermal keratinocytes and other cell types present in normal human skin. Other fixation protocols, including fixation regimens using formaldehyde or Carnoy's solution, were less suitable or unsuitable for detection of the receptor in cryostat sections of human skin.

Prevalence of HCV-RNA-positive blood donors and correlation to ELISA and RIBA status.

In Germany, transmission of hepatitis C virus by blood transfusion is prevented by screening the donations for anti-HCV and ALT. The specificity of the anti-HCV screening in low seroprevalence populations has been questioned. In order to evaluate this screening policy we wanted to estimate the prevalence of viremic and potentially infectious donors by the HCV-RNA polymerase chain reaction (PCR) in our donor population of southern Germany. Donors (n = 301) were divided into four subgroups according to anti-HCV status and ALT levels. HCV sequences were detected by nested PCR, using primers for the most conserved region of the viral genome. The recombinant immunoblot assay (RIBA-4) was applied to the same samples. PCR detected 4.2% HCV-RNA carriers in the subgroup anti-HCV-/ALT-; 3% in the subgroup anti-HCV-/ALT+; 19.4% in the subgroup anti-HCV+/ALT-; and 59.4% in the subgroup anti-HCV+/ALT+. It was concluded that, on the one hand, the lack of specificity of the anti-HCV ELISA gives rise to many false-positive results; on the other hand, a minority of infected donations will not be detected by the screening procedure. ALT in conjunction with anti-HCV improves the quality of screening for potentially infectious donors.

The serology of hepatitis C virus (HCV) infection: antibody crossreaction in the hypervariable region 1.

We determined the NS1/E2 N-terminal sequence including the hypervariable region 1 (HVR1) from five individuals chronically infected with HCV: two from the Czech Republic and three from Germany. From each sequence, six 12-mer overlapping peptides were synthesized and used in a peptide scan to evaluate seroreactivity of each of those patients, as well as three anti-HCV positive blood donors to the different isolates. We could show the general presence of antibodies to multiple HVR1 specific sequences reflecting the existence of multiple variants in infected persons. Finally, we observed the persistance of HCV infections in all individuals despite an active humoral response directed against the virus.

HCV transmission through blood transfusion: are HCV-RNA titer in donor serum and genotype major determinants of infection outcome?

In this paper we report the results of a retrospective investigation on anti-HCV supplemental test positive blood donors from 1993 and 1994. 22 living recipients of blood/blood components from 15 donors were localized and enrolled in the study. Serum from these individuals were tested by serological assays and RT/PCR. HCV-RNA titer was determined for all positive donors. Genotyping was performed for all HCV-RNA positive individuals (donors and recipients). We observed that less than 50% of the recipients of previous donations from those positive donors did develop serological markers of HCV infection. HCV-RNA titers in donor's serum varied from 2 x 10(3) to 5 x 10(5) copies/ml but a direct correlation between viral RNA titer and the outcome of infection could not be established. Genotype investigation revealed 100% identity of genotypes within the pairs of donors/recipients. Genotype 1 b reached a prevalence of 75% within this group.

Analysing the sequence diversity of the 5' NC-region of HCV-isolates found in southern Germany.

In this study we compared the nucleotide sequence of the 5' NC-region of the HCV genome isolated from seven patients and two blood donors from Southern Germany. We could identify two very distinct groups of isolates: the first very similar to the HCV prototype sequence (HCV1) with homology ranging from 99.5% to 98.7%; the second showing 91.7% homology to the HCV1. Group 1 isolates could be found in five patients and the two blood donors. Group 2 isolates could be found in the two other patients. Finally, we could observe neither nucleotide insertion nor deletion in the isolates described here.

Investigating the presence of HIV sequences and the distribution of virological markers in hemophiliacs and their sexual partners.

In this study, we report the investigation of a hemophiliac cohort, in which the last HIV-1 seroconversion occurred in 1985. We wanted to evaluate whether 5 years later the results of serological screening and polymerase chain reaction (PCR) technology would match. We examined 61 German patients with congenital deficiencies of factors VII, VIII-c, and IX, and 16 sexual partners (15 partners of anti-HIV-1-negative hemophiliacs). Patients' and partners' anti-HIV-1 status was determined by ELISA and Western blot. Further, we applied the PCR to investigate the possible presence of HIV sequences in anti-HIV-1-negative individuals. Four sets of primers were used in four separated reactions to avoid false-negative results due to genetic variation, as well as false-positive results due to DNA carryover. The data by PCR were not different from the data attained by conventional serological methods. The prevalence of serological markers for HBV and HCV was determined.

Isotype-specific immune response to a single hepatitis C virus core epitope defined by a human monoclonal antibody: diagnostic value and correlation to PCR.

In this study we tested the seroreactivity of 223 selected anti-HCV-reactive blood donors to the human B-cell epitope N-VYLLPR-C (C34-39) of the hepatitis C virus core antigen. The epitope was recently identified and characterized by the human monoclonal IgG antibody Ul/F10 and is located within the amino acid residues 34-39 of the aminoterminal core region. The blood donor sera were selected from anti-HCV ELISA (Ortho, 2nd generation)-reactive samples. Sixty-seven of these sera were further reactive in RIBA (Ortho, 2nd generation). According to their RIBA pattern, these samples were divided into four groups. Samples in the first group (n = 18) reacted to all four recombinant HCV antigens. The samples of the second (n = 9) and third group (n = 8) reacted to c22-3/c33c and c22-3/c100-3, respectively. Sera from group 4 (n = 32) showed a RIBA indeterminate pattern with reactivity only to c22-3. All 223 samples were analyzed for anti-C34-39 antibodies by ELISA, and the 67 RIBA-reactive samples were additionally tested for the presence of HCV RNA by RT/PCR. In groups 1 and 2, over 80% of the samples showed anti-C34-39 reactivity which was restricted to the IgG1 isotype. In contrast, in groups 3 and 4, antibodies to the epitope C34-39 were detected in less than 10% of the samples. Interestingly, the anti-C34-39 response correlates with the presence of HCV RNA; 95.5% of the samples had coincident results in all subgroups. None of the RIBA-negative sera showed a specific seroreaction to the C34-39 peptide.