Transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP): review of the literature on a novel surgical approach in the management of benign prostatic enlargement.

PURPOSE: Retrograde transurethral anatomical enucleation of the prostate is gaining momentum as a new concept in transurethral surgery of benign prostatic hyperplasia. Its adaptation is boosted by the familiarity of urologists with the finger-assisted anatomical enucleation of the adenoma during open prostatectomy and the combination of this well-established concept with the minimal invasive characteristics of transurethral surgery. The thulium laser appears as an ideal energy source for such operation. In this work, current evidence on thulium laser-assisted anatomical enucleation of the prostate (ThuLEP) is being reviewed. MATERIALS AND METHODS: A comprehensive literature review was performed on Medline, PubMed, and Cochrane databases retrieving all literature on thulium laser-assisted prostatectomy between 2006 and 2015. Experimental studies, review articles and editorial comments as well as studies on thulium laser-assisted approaches other than ThuLEP (i.e., ThuVEP, ThuVAP or ThuVARP) were excluded from the analysis. RESULTS: In total, six original articles on either surgical technique or clinical outcomes were retrieved. With regard to functional results, ThuLEP presented no significant differences toward the standard treatment (TURP/HoLEP) arm in two randomized controlled trials and favorable outcomes in available prospective cohorts. Observed morbidity was minimum and comparable with the rest of transurethral literature. CONCLUSIONS: ThuLEP literature is still very limited. Based on the available data, the approach is safe and effective, demonstrating favorable outcomes, comparable with the current standard treatment options. Further documentation of ThuLEP outcomes is necessary to define the optimum indications of this novel technique.

Laparoendoscopic partial nephrectomy in single-incision triangulated umbilical surgery (SITUS) technique: early experience.

BACKGROUND: Nephron sparing surgery for renal tumors has evolved as the standard of care for resectable renal tumors. Laparoscopic partial nephrectomy (PN) has gained recognition after technical refinements were able to match the well-established criteria for open partial nephrectomy. Laparoendoscopic surgery (LESS) is one of the approaches to further minimize invasiveness of laparoscopic surgery. OBJECTIVE: We report our initial experience with LESS partial nephrectomy in single-incision transumbilical surgery technique (SITUS) in daily clinical practice. DESIGN, SETTING, AND PARTICIPANTS: From 2010, patients undergoing SITUS-PN were prospectively evaluated. Patients with small, solitary or multiple, exophytic-enhancing renal masses were selected, whereas patients with solitary kidney, endophytic or hilar tumors were excluded. Important clinical data, PADUA and RENAL score, were assessed prospectively. MEASUREMENTS: Patients' characteristics, perioperative, hematologic and pathologic data as well as pain evaluation using the visual analogue pain scale (VAPS) were assessed. RESULTS AND LIMITATIONS: A total of 13 patients underwent LESS-PN/SITUS-PN (6 right and 7 left renal units). One patient was converted to conventional laparoscopy requiring two additional ports to treat bleeding from renal vessels. Pathology revealed renal cell carcinoma in nine patients, oncocytoma in one and benign cyst in three patients. No positive surgical margin was observed. The mean blood loss was 2.1 g/dl [range 0.5-4.5 g/dl] in hemoglobin. Minimal discomfort was noted at discharge (VAPS = 0.2 ± 0.6 [range 0-2]/10]. CONCLUSION: LESS partial nephrectomy in SITUS technique is feasible for selected exophytic tumors and has been integrated into our armamentarium for nephron sparing minimally invasive surgical treatment.

Current evidence of transurethral Ho:YAG and Tm:YAG treatment of bladder cancer: update 2014.

INTRODUCTION: Bladder cancer (BC) represents a growing health care problem worldwide. In times of tight budgets and an aging society, new strategies for the transurethral treatment of BC are needed. Laser devices used for tumor vaporization and/or en bloc resection provide an alternative to parvenu strategies. MATERIALS AND METHODS: Medline/Cochrane search was performed using following terms: bladder cancer, urothelial carcinoma, laser, en bloc, vaporization, photoablation, holmium, thulium, Ho:YAG, Tm:YAG, HoLRBT and TmLRBT. Last date of search was February 12, 2014. RESULTS: Eighteen publications in English were identified including 800 patients (Ho:YAG = 652 patients and Tm:YAG = 148 patients). Data on en bloc resection techniques were presented in 10 publications, 7 publications provided data of tumor vaporization and one publication presented data on both. Level of evidence based on SIGN is mainly 3 (non-analytic studies); only three studies are level 2 (prospective case control studies). Tumor vaporization seems to be a promising alternative for the treatment of recurrent tumors in selected patients. It can be performed in an office-based approach without the need of general anesthesia. The use of photodynamic diagnostic might enhance surgical quality. The principle of en bloc resection should provide accurate staging in most cases; however, data on this important aspect are missing. Peri- and postoperative complications are scarce. Due to the nature of the energy source, bladder perforation caused by obturator nerve reflex is highly unlikely when using lasers. There is a trend toward decreased infield recurrence rates. CONCLUSIONS: Lasers are potentially useful alternatives to conventional TURBT, but systematical assessments using standardized classification systems and well-designed RCTs are needed to make results comparable.

Superiority of the EF-120-00-3F biopsy forceps in the histopathological evaluation of upper urinary tract specimens.

PURPOSE: The purpose of this study was to analyze the efficacy of two different biopsy forceps with respect to their functionality and quality for histological assessment of upper urinary tract biopsies. METHODS: We compared flow rates, active deflection angle and histological quality of specimens taken from upper urinary tract biopsies of 40 consecutively treated patients between October 2011 and October 2012. Two different biopsy forceps [group A = 20 patients: "Piranha (®) " (Boston Scientific, Natick, USA) versus group B = 20 patients: "EF-120-00-3F" (Euromedical GmbH, Siegsdorf, GER)] were assessed. RESULTS: The specimens obtained with the "EF-120-00-3F" were superior in terms of tissue preservation such as intact urothelium/tissue fragmentation and the prevention of artifacts due to tissue compression (existence of artifacts/nucleus evaluation). Furthermore, due to superiority of tissue preservation, tissues obtained with the "EF-120-00-3F" showed better tissue orientation in the sense of anatomic evaluation of invasion and deep layer involvement. Irrigation flow rates did not differ significantly while deflection angle was more impaired with the "Piranha" biopsy forceps. No difference was observed with the handling of both biopsy forceps. CONCLUSIONS: We conclude that the "EF-120-00-3F" biopsy forceps represent a valuable modification of antegradely insertable instruments that qualifies for improved and correct staging as well as diagnosis of upper urinary specimens in comparison with standard biopsy forcipes.

New ex vivo organ model for percutaneous renal surgery using a laparoendoscopic training box: the sandwich model.

PURPOSE: Percutaneous renal surgery (PRS) is a challenging procedure for urologic surgeons and requires a large variety of different skills. Our objective was to improve the preexisting porcine kidney-training model for percutaneous renal access and PRS. METHODS: For our biologic training model, we use porcine kidneys with preserved ureter. The ureter was dissected, stones were placed into the collecting system using a 16, 5F Amplatz sheath, and a 12Ch indwelling catheter was placed in the ureter for further irrigation with blue-dyed saline. The kidney was placed between two porcine full-thickness skin lobes in an existing laparoscopy trainer (SITUS Box). The kidney was punctured with ultrasound guidance, and minimally invasive percutaneous nephrolithotomy (MIP) was then performed as previously described. The model was evaluated in MIP training courses, which are regularly held at the Hannover Medical School. RESULTS: All trainees were urologists with experience in endourologic surgery. Eleven participants were trained in this model. Percutaneous puncture under ultrasonographic guidance and following intrarenal surgery was successful in all 11 (100 %) cases. Therefore, all participants rated the model useful for simulating percutaneous renal surgery. CONCLUSION: Compared to recently published models, this new porcine kidney model is easy to prepare and is cost-effective by using standard material. Moreover, it provides realistic and reproducible practice for PRS in the laboratory. Unfavorably, the described organ model requires an existing laparoscopy training system. Comprehensively, the presented organ model approximates the natural retroperitoneal circumstances precisely by using the two full-thickness skin flaps with the fatty subcutaneous tissue.

The biological activity of botulinum neurotoxin type C is dependent upon novel types of ganglioside binding sites.

The seven botulinum neurotoxins (BoNT) cause muscle paralysis by selectively cleaving core components of the vesicular fusion machinery. Their extraordinary activity primarily relies on highly specific entry into neurons. Data on BoNT/A, B, E, F and G suggest that entry follows a dual receptor interaction with complex gangliosides via an established ganglioside binding region and a synaptic vesicle protein. Here, we report high resolution crystal structures of the BoNT/C cell binding fragment alone and in complex with sialic acid. The WY-motif characteristic of the established ganglioside binding region was located on an exposed loop. Sialic acid was co-ordinated at a novel position neighbouring the binding pocket for synaptotagmin in BoNT/B and G and the sialic acid binding site in BoNT/D and TeNT respectively. Employing synaptosomes and immobilized gangliosides binding studies with BoNT/C mutants showed that the ganglioside binding WY-loop, the newly identified sialic acid-co-ordinating pocket and the area corresponding to the established ganglioside binding region of other BoNTs are involved in ganglioside interaction. Phrenic nerve hemidiaphragm activity tests employing ganglioside deficient mice furthermore evidenced that the biological activity of BoNT/C depends on ganglioside interaction with at least two binding sites. These data suggest a unique cell binding and entry mechanism for BoNT/C among clostridial neurotoxins.