Robot-Assisted versus Laparoscopic Donor Nephrectomy: A Comparison of 250 Cases.

Living kidney donation is the best treatment for end-stage renal disease, however, the best surgical approach for minimally-invasive donor nephrectomy (DN) is still a matter of debate. This bi-centric study aimed to retrospectively compare perioperative outcomes and postoperative kidney function after 257 transperitoneal DNs including 52 robot-assisted (RDN) and 205 laparoscopic DNs (LDN). As primary outcomes, the intraoperative (operating time, warm ischemia time (WIT), major complications) and postoperative (length of stay, complications) results were compared. As secondary outcomes, postoperative kidney and graft function were analyzed including delayed graft function (DGF) rates, and the impact of the surgical approach was assessed. Overall, the type of minimally-invasive donor nephrectomy (RDN vs. LDN) did not affect primary outcomes, especially not operating time and WIT; and major complication and DGF rates were low in both groups. A history of smoking and preoperative kidney function, but not the surgical approach, were predictive for postoperative serum creatinine of the donor and recipient. To conclude, RDN and LDN have equivalent perioperative results in experienced centers. For this reason, not the surgical approach, but rather the graft- (preoperative kidney function) and patient-specific (history of smoking) aspects impacted postoperative kidney function.

Development of Graft-Site Candidiasis in 3 Solid Organ Transplant Recipients from the Same Donor.

BACKGROUND Graft-site candidiasis rarely develops in solid organ transplant recipients; however, severe life-threatening complications can occur. We report the course of 3 solid organ transplant recipients developing graft-site candidiasis. CASE REPORT All grafts, consisting of 2 kidneys and 1 liver, were procured from a single donor. Patient data were collected from our database. Candida albicans was isolated from a swab taken during multiple-organ recovery. Complications associated with candidiasis occurred in all 3 recipients with preservation of the liver transplant. Both renal transplant recipients had vascular complications, eventually resulting in graft nephrectomy and subsequent return to dialysis. The patients recovered completely without residual effects of their prior fungal infection. CONCLUSIONS Fungal infections in solid organ transplant recipients are rare. Since the sequelae of these infections are serious and usually pertain to more than 1 recipient at a time, antifungal prophylaxis may be warranted in select donors.

Anatomical and surgical study of volume determination of the anterolateral epidural space nerve root L5/S1 under the aspect of epidural perineural injection in minimal invasive treatment of lumbar nerve root compression.

Herniated intervertebral disc causes in a great number of cases of lumbar nerve root compression, especially in the segment L5/S1. Other reasons responsible for stress to the lumbar spinal root are the spinal canal stenosis and the postdiscotomy syndrome. For patients without neurological deficiencies, the conservative treatment includes different epidural injection techniques. Steroids are often applied. A specific injection technique needing only a small drug amount is the epidural perineural approach using a special two-needle technique. The anatomical spaces of the nerve roots have received little attention in therapy. We have determined the anterolateral epidural space nerve volume of the nerve root L5/S1, and compared the data collected in an anatomical study with operative measurements during discectomy. The volume determination in the human cadavers was performed with liquid silicone filling the anterolateral space after dissection. The in vivo measurements were performed during surgery at the site of the anterolateral space after discectomy. The anatomical studies showed us a mean value volume of 1.1 ml. The surgical volume determinations result in a mean volume of 0.9 ml. A better understanding of the anterolateral epidural space may allow a reduction of the injection volume in the conservative nerve root compression treatment, especially using the epidural perineural technique, avoiding the risk of side effects of high doses of steroids.

Relationship satisfaction and erectile functions in men receiving laparoscopic radical prostatectomy: effects of provision and receipt of spousal social support.

INTRODUCTION: Prostate carcinoma ranges among the most common cancers in German men. One of its standard treatments is radical prostatectomy (RP). Postoperative comorbidities of RP include erectile dysfunctions, which may impact patients' relationship quality. Little is known, to date, about patients' and their partners' psychosocial resources that might reduce the risk of damage to relationship outcomes. Such resources include spousal social support interactions. AIM: We investigated cross-sectional and prospective relations of patient-reported and partner-reported received and provided spousal support, and patients' indicators of erectile functions and relationship satisfaction prior to and 1 year following laparoscopic radical prostatectomy. MAIN OUTCOME MEASURES: Patient-reported relationship satisfaction (Relationship Questionnaire; Fragebogen zur Partnerschaftsdiagnostik) and erectile functions (International Index of Erectile Function) were investigated as main outcomes. METHODS: One hundred thirty-nine patients and their heterosexual partners provided data prior to and 12 months after the operation. Main outcomes were patient-reported relationship satisfaction and erectile functions. In addition to several covariates, central predictors were patients' and partners' accounts of received and provided spousal support. Data were assessed using questionnaires. RESULTS: Erectile functions were associated with patients' relationship satisfaction presurgery, but not 12 months postsurgery. Patient-reported received and provided support was positively associated with relationship satisfaction at all times. Patient-reported provision of support was also related with better erectile functions prior to and postsurgery. Some of these associations could be replicated using partner accounts of respective support indicators. CONCLUSIONS: Regarding patients' relationship satisfaction and sexual functions, findings associate more consistent benefit with patients' own provision of supports when compared with their own support receipt.

Different prostate-specific antigen assays give different results on the same blood sample: an obstacle to recommending uniform limits for prostate biopsies.

OBJECTIVE: To show the effect of different results for total prostate specific antigen (tPSA) and percentage free/total PSA (%fPSA) obtained with different assays for differentiating between benign and malignant prostate diseases. PATIENTS AND METHODS: Data were used for tPSA and fPSA levels from 596 patients with prostate cancer (314) or no evidence of cancer (282) within the PSA range 0.5-10 ng/mL, analysed with assays from Abbott (AxSYM), Beckman Coulter (Access), DPC (Immulite 2000), and Roche (Elecsys 2010), and with tPSA and complexed PSA (cPSA) assays from Bayer (ADVIA Centaur), as already reported. Receiver operating characteristics (ROC), specificities at assay-dependent and fixed thresholds, and the percentages of correct classification rates of patients were calculated. RESULTS: Whereas the areas under the ROC curves were no different among all tPSA assays, the assay-specific thresholds at 90% sensitivity were 2.5-3.1 ng/mL. When using fixed 2.5 or 4 ng/mL tPSA thresholds there was a wide sensitivity range, with significant differences among almost all assays, resulting in significantly different classification rates of patients. These differences were even larger when using fixed %fPSA thresholds. CONCLUSIONS: The current situation of differences among PSA values measured with different assays do not allow the recommendation of uniform PSA limits as biopsy criteria. For that purpose, better harmonization of PSA values between the different PSA test systems must be realized.

Electrophoretic subforms of free prostate-specific antigen in serum as promising diagnostic tool in prostate cancer diagnostics.

OBJECTIVES: To assess the diagnostic performance of the major electrophoretic subforms of free prostate-specific antigen (PSA), named F2 and F3, for differentiating between benign and malignant prostatic disease in men with total PSA (tPSA) concentrations up to 10 microg/L. METHODS: In sera from 50 patients with prostate cancer (PCa) and 44 men without evidence of malignancy (NPCa), F2 and F3 were quantified by two-dimensional electrophoresis and Western blotting. The F2/F3 ratios were compared with the conventional parameter tPSA and percentage fPSA/tPSA ratio (%fPSA) in univariate and multivariate analyses using receiver operating characteristic analysis. RESULTS: F2 was lower in the NPCa group (median 17%) than in the PCa group (55%), and F3 was greater in the NPCa group (62%) than in the PCa group (45%), resulting in a significantly lower F2/F3 ratio in the NPCa group than in the PCa group (0.32 versus 1.21). The F2/F3 ratio correlated with the %fPSA and prostate volume but not Gleason score, tumor stage, age, or tPSA. The F2/F3 ratio and F2-F3/%fPSA ratio had greater areas under the receiver operating characteristic curves than did tPSA or %fPSA, especially in the subgroup of %fPSA greater than 15%. Models of binary logistic regression confirmed the improvement of diagnostic accuracy using the F2/F3 ratio as an independent variable. CONCLUSIONS: Compared with tPSA and %fPSA, the fPSA subforms F2 and F3, assessed as F2/F3 or F2-F3/%fPSA ratios, enhanced the differentiation between men with and without PCa for tPSA levels up to 10 microg/L. Additional characterization of these forms should be performed to develop a feasible assay.

Acupuncture and knee osteoarthritis: a three-armed randomized trial.

BACKGROUND: Despite the popularity of acupuncture, evidence of its efficacy for reducing pain remains equivocal. OBJECTIVE: To assess the efficacy and safety of traditional Chinese acupuncture (TCA) compared with sham acupuncture (needling at defined nonacupuncture points) and conservative therapy in patients with chronic pain due to osteoarthritis of the knee. DESIGN: Randomized, controlled trial. SETTING: 315 primary care practices staffed by 320 practitioners with at least 2 years' experience in acupuncture. PATIENTS: 1007 patients who had had chronic pain for at least 6 months due to osteoarthritis of the knee (American College of Rheumatology [ACR] criteria and Kellgren-Lawrence score of 2 or 3). INTERVENTIONS: Up to 6 physiotherapy sessions and as-needed anti-inflammatory drugs plus 10 sessions of TCA, 10 sessions of sham acupuncture, or 10 physician visits within 6 weeks. Patients could request up to 5 additional sessions or visits if the initial treatment was viewed as being partially successful. MEASUREMENTS: Success rate, as defined by at least 36% improvement in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 26 weeks. Additional end points were WOMAC score and global patient assessment. RESULTS: Success rates were 53.1% for TCA, 51.0% for sham acupuncture, and 29.1% for conservative therapy. Acupuncture groups had higher success rates than conservative therapy groups (relative risk for TCA compared with conservative therapy, 1.75 [95% CI, 1.43 to 2.13]; relative risk for sham acupuncture compared with conservative therapy, 1.73 [CI, 1.42 to 2.11]). There was no difference between TCA and sham acupuncture (relative risk, 1.01 [CI, 0.87 to 1.17]). LIMITATIONS: There was no blinding between acupuncture and traditional therapy and no monitoring of acupuncture compliance with study protocol. In general, practitioner-patient contacts were less intense in the conservative therapy group than in the TCA and sham acupuncture groups. CONCLUSIONS: Compared with physiotherapy and as-needed anti-inflammatory drugs, addition of either TCA or sham acupuncture led to greater improvement in WOMAC score at 26 weeks. No statistically significant difference was observed between TCA and sham acupuncture, suggesting that the observed differences could be due to placebo effects, differences in intensity of provider contact, or a physiologic effect of needling regardless of whether it is done according to TCA principles.

The long-term clinical sequelae of incidental durotomy in lumbar disc surgery.

STUDY DESIGN: A retrospective, long-term follow-up study. OBJECTIVES: To find out whether incidental durotomy in lumbar disc surgery is associated with long-term sequelae. SUMMARY OF BACKGROUND DATA: Incidental durotomy is a frequent complication during spinal surgery. Little is known about the clinical long-term outcome. METHODS: The study population comprised 1,280 patients who underwent standard discectomy of a lumbar disc herniation. A total of 41 patients with incidental durotomies (Group A) were compared with a control group (n = 41) (Group B) matched for age, sex, spinal level, and duration of follow-up. After a mean follow-up period of 10.2 years (Group A) or 10.3 years (Group B), the patients reported complaints, headache, and low back or leg pain. The patients' activity was assessed by means of a questionnaire concerning hindrance in daily activities, the Tegner score for general activities in daily life, and the Hannover Functional Ability Questionnaire for Measuring Back Pain-Related Functional Limitations (FFbH-R). The frequency of reoperation and the intake of analgesics were included. Furthermore, the patients' inability to work, change of profession, and retirement were registered. RESULTS: Patients with incidental durotomy had a poorer outcome after surgery. The Tegner score was significantly decreased for the group with dural tears. Furthermore, significant more patients with incidental durotomy complained about headaches after surgery. A strong tendency for worse outcome in Group A was shown in regard to reported complaints and daily activity. The patients with incidental durotomy had a tendency to more reoperations, a longer duration of inability to work, more back-pain, and functional limitations related to back-pain (FFbH-R). CONCLUSION: Our study revealed that incidental durotomy in lumbar disc surgery was associated with long-term clinical sequelae. We therefore conclude that dural tears bring about poor clinical outcome at the long-term follow-up.

The related outcome and complication rate in primary lumbar microscopic disc surgery depending on the surgeon's experience: comparative studies.

BACKGROUND CONTEXT: Studies concerning intraoperative complications and their influence on the clinical outcome of microscopic disc surgery are quite rare. Complication rates vary between 1.5% and 15.8%. A correlation between the surgeon's experience and the complication rate may be expected. PURPOSE: To determine the influence of the surgeon's experience on the intraoperative complication rate in lumbar microscopic disc surgery. STUDY DESIGN: Three studies are included: 1) retrospective analysis of intraoperative complications in microscopic disc surgery (N=1,872); 2) prospective follow-up study of microscopic disc surgery (N=583); 3) prospective evaluation of complication rates in microscopic disc surgery (N=90). PATIENT SAMPLE: Patient data sets from 1,872 lumbar microscopic disc surgeries performed between January 7, 1981, and June 31, 2000, were examined in a retrospective study. A total of 463 patients, operated on between 1991 and 1996, were followed up by a questionnaire. Finally, a prospective controlled trial (N=90) was performed. OUTCOME MEASURES: Such complications as incidental durotomy, wrong level exposure, or bleeding were analyzed based on the patient data sets by a blinded external evaluator. The rates of lower back pain and ischiatic pain were measured on a visual analogue scale at follow-up in Study 2 and Study 3. To measure the outcome of surgery in daily life activities and functional capacity, the Tegner activity level was calculated. In addition, a questionnaire with the Hannover score was used. The patient's social and economic status was also recorded. METHODS: A total of 1,872 lumbar microscopic disc surgeries, performed between January 7, 1981 and June 31, 2000, were examined in a retrospective study. Intra- and perioperative complications were evaluated and related to the surgeons' level of experience. Patients in the first group (XL) were operated on by the most experienced surgeon (more than 500 microscopic discectomies before the beginning of the study). The L-group surgeons performed between 50 and 100 microscopic disc surgeries before the study. This group included a total number of seven surgeons during the 1981-2000 time frame. None of this group reached the experience level of 500 surgeries during the course of the study. A total of 463 patients, operated on between 1991 and 1996, were followed up. Finally, a prospective controlled trial (N=90) was performed. Injuries of the dura, nerve root, ventral structures and wrong level exposure, which had been detected and corrected during surgery, were analyzed. In the second and third study, the outcome was correlated to surgery and complications during surgery. RESULTS: The rate of intraoperative complications showed a statistically significant difference between the groups. The comparison of both groups (n=1,872) with regard to the rate of intraoperative complications showed a statistically significant difference between 2.2% in the XL group and 10.7% in the L group (p< or =.001). Regarding work-related and socioeconomic factors, no significant difference in the outcome was seen. CONCLUSIONS: Microscopic disc surgery requires a course of instruction and a considerable number of surgeries under supervision by experienced surgeons. To shorten the learning curve, a number of standardized surgery steps to clearly identify anatomical landmarks are helpful. During training, these landmarks can be checked by an experienced surgeon to minimize the rate of intraoperative complications. Initial postoperative ischiatic pain was correlated to an incidental durotomy with p<.001. For long-term results after disc surgery, however, socioeconomic and work-related factors are of greater importance in spinal disc surgery than the incidence of intraoperative complications.

Clinical symptoms in lumbar disc herniations and their correlation to the histological composition of the extruded disc material.

STUDY DESIGN: Fifty-five consecutive patients undergoing microdiskectomy due to lumbar disc herniation were included in this clinical study over 12 months. OBJECTIVES: To investigate possible correlations between the histologic composition of the herniated disc fragments and pain, disability, clinical signs, and operative findings. SUMMARY OF BACKGROUND DATA: Previous studies have investigated the histologic composition of herniated lumbar disc fragments. Few publications, however, examined correlations with clinical data. METHODS: Before treatment, patients were examined using a standardized clinical protocol; subjective disability and pain were assessed by the Oswestry Disability Questionnaire and the McGill Pain Questionnaire. The herniated disc fragments were examined semiquantitatively for the relative percentages of nucleus pulposus, anulus fibrosus, and cartilaginous endplate. RESULTS: In patients less than 30 years of age, significantly higher percentages of nucleus pulposus were found than in the older group, whereas anulus fibrosus was found in significantly higher percentages in patients > or =30 years. Both higher percentages of cartilage and nucleus pulposus correlated with increased pain intensity values from the McGill Pain Questionnaire. Impaired reflexes before treatment occurred significantly more often in patients with > or =20% of cartilage in the herniated fragments. If nucleus pulposus was <30%, sensory impairment tended to be more severe before treatment. CONCLUSION: The histologic composition of the herniated disc fragments seems to affect pain and clinical symptoms.

Efficacy and safety of acupuncture for chronic pain caused by gonarthrosis: a study protocol of an ongoing multi-centre randomised controlled clinical trial [ISRCTN27450856].

BACKGROUND: Controlled clinical trials produced contradictory results with respect to a specific analgesic effect of acupuncture. There is a lack of large multi-centre acupuncture trials. The German Acupuncture Trial represents the largest multi-centre study of acupuncture in the treatment of chronic pain caused by gonarthrosis up to now. METHODS: 900 patients will be randomised to three treatment arms. One group receives verum acupuncture, the second sham acupuncture, and the third conservative standard therapy. The trial protocol is described with eligibility criteria, detailed information on the treatment definition, blinding, endpoints, safety evaluation, statistical methods, sample size determination, monitoring, legal aspects, and the current status of the trial. DISCUSSION: A critical discussion is given regarding the considerations about standardisation of the acupuncture treatment, the choice of the control group, and the blinding of patients and observers.