Timing of surgery in acute deep partial-thickness burns: A study protocol.

For deep partial-thickness burns no consensus on the optimal treatment has been reached due to conflicting study outcomes with low quality evidence. Treatment options in high- and middle-income countries include conservative treatment with delayed excision and grafting if needed; and early excision and grafting. The majority of timing of surgery studies focus on survival rather than on quality of life. This study protocol describes a study that aims to compare long-term scar quality, clinical outcomes, and patient-reported outcomes between the treatment options. A multicentre prospective study will be conducted in the three Dutch burn centres (Rotterdam, Beverwijk, and Groningen). All adult patients with acute deep-partial thickness burns, based on healing potential with Laser Doppler Imaging, are eligible for inclusion. During a nine-month baseline period, standard practice will be monitored. This includes conservative treatment with dressings and topical agents, and excision and grafting of residual defects if needed 14-21 days post-burn. The subsequent nine months, early surgery is advocated, involving excision and grafting in the first week to ten days post-burn. The primary outcome compared between the two groups is long-term scar quality assessed by the Patient and Observer Scar Assessment Scale 3.0 twelve months after discharge. Secondary outcomes include clinical outcomes and patient-reported outcomes like quality of life and return to work. The aim of the study is to assess long-term scar quality in deep partial-thickness burns after conservative treatment with delayed excision and grafting if needed, compared to early excision and grafting. Adding to the ongoing debate on the optimal treatment of these burns. The broad range of studied outcomes will be used for the development of a decision aid for deep partial-thickness burns, to fully inform patients at the point of consent to surgery and support optimal person-centred care.

Learning curve and functional outcomes after laser enucleation of the prostate for benign prostate hyperplasia according to surgeon's caseload.

PURPOSE: To evaluate the impact of surgical caseload on safety, efficacy, and functional outcomes of laser enucleation of the prostate (LEP) applying a structured mentoring program. METHODS: Patient characteristics, perioperative data, and functional outcomes were analyzed descriptively. Linear and logistic regression models analyzed the effect of caseload on complications, functional outcomes and operative speed. Within the structured mentoring program a senior surgeon was present for the first 24 procedures completely, for partial steps in procedures 25-49, and as needed thereafter. RESULTS: A total of 677 patients from our prospective institutional database (2017-2022) were included for analysis. Of these, 84 (12%), 75 (11%), 82 (12%), 106 (16%), and 330 patients (49%) were operated by surgeons at (A) < 25, (B) 25-49, (C) 50-99, (D) 100-199, and (E) ≥ 200 procedures. Preoperative characteristics were balanced (all p > 0.05) except for prostate volume, which increased with caseload. There was no significant difference in change of IPSS, Quality of life, ICIQ, pad usage, peak urine flow, residual urine, and major complications (Group A: 8.3 to E: 7.6%, p = 0.2) depending on the caseload. Caseload was not associated (Odds ratio: 0.7-1.4, p > 0.2) with major complications in the multivariable logistic regression model. Only operating time was significantly shorter with increasing caseload in the multivariable analysis (111-55 min, beta 23.9-62.9, p < 0.001). CONCLUSION: With a structured mentoring program, the safety and efficacy of LEP can be ensured even during the learning curve with very good outcome quality. Only the operating time decreases significantly with increasing experience of the surgeon.

Surgical treatment of large volume prostates: a matched pair analysis comparing the open, endoscopic (ThuVEP) and robotic approach.

OBJECTIVE: To compare open simple prostatectomy, endoscopic enucleation and laparoscopic, robot-assisted enucleation of high-volume prostate in terms of operation time, blood loss, transfusion and complication rates and early continence rates. MATERIAL AND METHODS: Patients with BPH treated endoscopically (ThuVEP, Hamburg and Hannover) or robotically (Mainz) were evaluated prospectively for prostate size, free flow and validated questionnaires (IPSS, QoL). 35 patients were matched to patients after open prostatectomy (Mainz) for age, prostate size, IPSS and QoL scores. Operation time was noted from the first cut to the last suture; blood loss was estimated by the drop of haemoglobin preoperatively and one day after surgery. Transfusion rates were documented. Early continence was estimated by pad use over the first 24 h after catheter removal. Statistical analysis was performed with SPSS 22.0. RESULTS: No significant differences in prostate size, age and preoperative questionnaires were found (p > 0.3). Postoperative flow and the results of the questionnaires were significantly improved (all p < 0.05), without difference between the approaches (p > 0.8). Endoscopic surgery showed superiority in operation time (both p < 0.05); blood loss and transfusion rates were significantly lower compared to open surgery (both p < 0.01) and lower than in robotic surgery without reaching significance (p = 0.18, p = 0.36). Similar results were seen in early continence rates. CONCLUSION: Due to our results, endoscopic surgery should be considered as first-line therapy unless there are comorbidities like diverticula and/or bladder calculi that can be easily treated simultaneously by robotic surgery. Against the background of these findings, indications favouring open surgery are getting sparse.

Survival outcomes in patients with large (≥7cm) clear cell renal cell carcinomas treated with nephron-sparing surgery versus radical nephrectomy: Results of a multicenter cohort with long-term follow-up.

BACKGROUND: Does the dogma of nephron sparing surgery (NSS) still stand for large renal masses? Available studies dealing with that issue are considerably biased often mixing imperative with elective indications for NSS and also including less malignant variants or even benign renal tumors. Here, we analyzed the oncological long-term outcomes of patients undergoing elective NSS or radical tumor nephrectomy (RN) for non-endophytic, large (≥7cm) clear cell renal carcinoma (ccRCC). METHODS: Prospectively acquired, clinical databases from two academic high-volume centers were screened for patients from 1980 to 2010. The query was strictly limited to patients with elective indications. Surgical complications were retrospectively assessed and classified using the Clavien-Dindo-classification system (CDS). Overall survival (OS) and cancer specific survival (CSS) were analyzed using the Kaplan-Meier-method and the log-rank test. RESULTS: Out of in total 8664 patients in the databases, 123 patients were identified (elective NSS (n = 18) or elective RN (n = 105)) for ≥7cm ccRCC. The median follow-up over all was 102 months (range 3-367 months). Compared to the RN group, the NSS group had a significantly longer median OS (p = 0.014) and median CSS (p = 0.04). CONCLUSIONS: In large renal masses, NSS can be performed safely with acceptable complication rates. In terms of long-term OS and CSS, NSS was at least not inferior to RN. Our findings suggest that NSS should also be performed in patients presenting with renal tumors ≥7cm whenever technically feasible. Limitations include its retrospective nature and the limited availability of data concerning long-term development of renal function in the two groups.

[Systemic immune checkpoint inhibition : A promising treatment for urological tumors?] / Systemische Immuncheckpoint-Inhibition : Eine vielversprechende Therapie urologischer Tumoren?

Improved understanding of the immunomodulatory interactions between tumor cells and immune cells has led to new and promising systemic therapeutic approaches in the first- and second-line therapy of urological tumors. Particularly in the case of urothelial carcinoma, for the first time in 20 years, checkpoint inhibitors (PD-1 and PDL-1 inhibitors) provide well-tolerated therapy that achieves response rates of >20% that can be sustained over the long term. This review explains the approach of immunotherapy and summarizes the current phase III clinical situation on urothelial carcinoma and renal cell carcinoma. The current immunomodulatory therapeutic approaches for prostate cancer are discussed. Finally, we highlight new immunomodulatory therapeutic approaches in basic research.

[Splice variant AR-V7 : Is it time for its routine use as a predictive marker in prostate cancer?] / Spleißvariante AR-V7 : Ist die Zeit reif für ihre routinemäßige Anwendung als prädiktiver Marker beim Prostatakarzinom?

Androgen receptor splice variants (AR-Vs), if overexpressed, lack the ligand-binding domain conveying metastasized castration-resistant prostate cancer with a therapeutic resistance to androgen receptor signaling inhibitors. Particularly AR-V7 has recently been proposed as a potential predictive biomarker to identify patients who would probably benefit most from taxane-based cytotoxic treatment. Several assays to substantiate or quantify AR-V7 expression have recently been proposed. However, their broad clinical value is still debatable. This contemporary update aims to shed light on the current evidence in the field and draw distinct practical conclusions.

[Urolithiasis 2016 : Reliable, effective and low radiation exposure]. / Steindiagnostik 2016 : Zuverlässig, effektiv und strahlungsarm.

BACKGROUND: Urolithiasis is a widespread disease. Diagnostic imaging plays an important role in the evaluation and management of patients with suspected urolithiasis. Furthermore, modern imaging methods may provide information on stone location, size, fragility and composition aiding the urologist to determine the appropriate treatment modality. PURPOSE: Based on the current literature and guidelines, this review reports on the various new and established diagnostic imaging modalities. RESULTS: Ultrasound should always be the initial imaging modality. Following ultrasound, noncontrast CT-principally using a low-dose protocol-is the imaging modality of choice in the evaluation of patients with acute flank pain and suspected urolithiasis. New imaging modalities like dual energy CT, Uro Dyna CT and digital tomosynthesis are currently under investigation but not yet part of daily clinical practice. Magnetic resonance imaging can be used to detect obstruction caused by urinary stones but is not a first-line imaging modality.

[Perioperative Outcomes in Correlation to the Learning Curve for Robotic Assisted Partial Nephrectomy: The First 109 Cases of our Clinic]. / Perioperatives Outcome in Korrelation zur Lernkurve bei robotisch assistierter partieller Nephrektomie: Die ersten 109 Fälle unserer Klinik.

BACKGROUND: In contrast to conventional laparoscopic partial nephrectomy, the approach of robot-assisted partial nephrectomy (RAPN) shows a steep learning curve with shorter warm ischaemia times (WIT) and comparable postoperative outcomes. Therefore RAPN is considered a good minimally-invasive surgical procedure for patients presenting with a renal cell carcinoma in clinical stage cT1a. The aim of the presented study was to evaluate the perioperative outcomes of our patients after RAPN and to illustrate the learning curve based on characteristic perioperative parameters such as WIT. MATERIAL AND METHODS: The data of 109 patients treated by RAPN in our clinic between January 2010 and April 2015 were retrospectively analysed regarding perioperative, laboratory and oncological outcomes. Postoperative complications until 30 days after surgery were documented. We analysed the data of the largest patient population treated by a single urologist, comparing WIT, operating time, blood loss and decline of the glomerular filtration rate between the first and the second 30 consecutive cases. RESULTS: Mean WIT was 18.4 min (SD±10.2), mean operating time was 199 min (SD±20), and mean estimated blood loss was 657 millilitres (SD±715 ml). Mean loss of GFR was reported to be 4.99 mg/dl/1.73 m (2) (SD±15.44). 83 (76%) malignant lesions were removed. 11 patients (10%) had a R1 resection, one patient had a R2 resection and in 2 cases the resection status was Rx. 22% of patients developed postoperative complications. Intraoperative complications were documented in 2 cases. According to the Clavien-Dindo Classification, 6% of patients had grade 1 and 2 complications and 13% developed grade 3 and 4 complications. WIT was significantly lower after 30 consecutive cases treated by one urologist. Regarding operating time, GFR or blood loss no significant correlation was found. CONCLUSION: Our data is in line with the surgical outcomes described in the literature. RAPN is a safe surgical technique with a steep learning curve. In our experience, 30 surgical cases provide a urologist with sufficient expertise to achieve good perioperative results. Weaknesses of this report include the retrospective design and insufficient documentation in some cases.

[Asymptomatic kidney stones: active surveillance vs. treatment]. / Asymptomatische Nierensteine: Wann Active Surveillance, wann Therapie?

The prevalence of kidney stones is increasing worldwide. Asymptomatic non-obstructing kidney stones are increasingly detected as an incidental finding on radiologic imaging, which has been performed more frequently over the last decades. Beside the current interventional treatment modalities such as extracorporeal shockwave lithotripsy (ESWL), ureterorenoscopy (URS) and percutaneous nephrolithotomy (PNL), active surveillance of asymptomatic kidney stones has been a focus of discussion lately, not only for attending physicians, but even more so for patients. The current German and European guidelines recommend active surveillance for patients with asymptomatic kidney stones if no interventional therapy is mandatory because of pain or medical factors. Herein we review the current literature on risks and benefits of active surveillance of asymptomatic non-obstructing kidney stones.

[Robotic-assisted radical prostatectomy]. / Robotisch assistierte radikale Prostatektomie.

BACKGROUND: Robot-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted as a standard approach for surgical treatment of organ-confined prostate cancer. Despite additional costs, RALP seems to provide better functional and oncological outcomes and less blood loss compared to open radical prostatectomy (ORP). However, prospective randomized studies are still missing. PURPOSE: Based on the current literature, this review reports about the role of RALP in prostate cancer treatment. Its functional and oncologic outcomes as well as complication rates are compared to ORP. Particularly, the role of RALP in nonorgan-confined tumors will be discussed. RESULTS: Based on the current literature, RALP provides better continence and potency rates as compared to ORP. Moreover, the incidence of positive surgical margins seems to be reduced. However, there is conflicting data regarding the role of RALP in nonorgan-confined prostate cancer. Regarding long-term oncologic outcomes, RALP seems to be comparable to ORP.

[Robot-assisted laparoscopic partial nephrectomy: functional and oncological outcomes]. / Robotisch assistierte laparoskopische partielle Nephrektomie : Funktionelle und onkologische Ergebnisse.

BACKGROUND: In recent years, small renal masses (SRM) have been increasingly detected as an incidental finding of radiological or ultrasound studies for other indications. Organ-sparing renal tumor resection as open partial nephrectomy (OPN) is the international standard for renal tumors <7 cm. RESULTS: Due to technical developments, minimally invasive procedures have emerged as an alternative to OPN. In experienced hands, conventional laparoscopic partial nephrectomy (LPN) has achieved good functional and oncological results comparable to OPN. Robot-assisted laparoscopic partial nephrectomy (RAPN) has been performed since 2004. Compared to LPN, RAPN provides a faster learning curve, better visualization and more versatile instrumentation due to the degrees of freedom of the articulated instruments. After about 30 procedures, a level of experience is reached, which is characterized by good functional results, less blood loss, and shorter warm ischemia time of the kidney as compared to LPN. This can relate to a shorter hospital stay and faster recovery. Complications according to the Clavien classification are mostly grade I and II and are mainly treated conservatively. CONCLUSION: Oncological long-term results are not available yet; so that RAPN cannot be considered as an equivalent treatment to LPN and OPN. Until long-term evidence is available, decisions regarding the surgical technique for organ-sparing renal tumor resection will be determined by patient's wishes and surgeon's preference.

[Resecting hematogenous metastases: reasons against]. / Operation hämatogener Metastasen: Gründe dagegen.

Urological malignancies represent approximately 40% of all solid tumors. Synchronous or metachronous organ metastases develop in 30% of patients. Depending on the tumor entity and tumor characteristics, resection of metastases can improve patient survival. Surgical resection of residual tumors is an integral part of the multimodal therapy concept of patients with nonseminomatous metastatic germ-cell cancer. Surgical inoperability is the only reason not to resect. Resection of hematogenous metastases from renal cell carcinoma has been postulated as a standard therapy for decades. Appropriate patient selection is the key for a survival benefit. Prognosticators such as patient's general condition as well as number, location, and size of metastases help to counsel and select patients accordingly. Metastases of transitional cell or penile carcinoma should only be resected when a response to systemic treatment is evident in the individual case. There is no evidence in favor of resecting organ-metastases of prostate cancer in the current guidelines and the literature. In this article, arguments against resection of metastases following the current literature and guidelines are described.

[Importance of radical prostatectomy for patients older than 70 years]. / Stellenwert der radikalen Prostatektomie bei ≥ 70-Jährigen.

Surgical treatment of prostate cancer (PCa) in patients older than 70 years is controversially discussed. Although the prevalence and presumably also the aggressiveness of PCa increase with age, a survival advantage by radical prostatectomy (RPx) is questionable. The current review will discuss the oncological outcome of RPx in the elderly. Moreover, the pros and cons of different surgical approaches will be evaluated.

[Renal function in the elderly after radical tumor nephrectomy and partial nephrectomy]. / Nierenfunktion im Alter nach radikaler Tumornephrektomie und partieller Nephrektomie.

Due to rising life-expectancy and increasing use of tomography more elderly patients with incidental renal tumors are being diagnosed. The current article gives an overview of kidney function after renal surgery in the elderly and the aim is to give assistance in clinical practice for deciding how to adequately treat these patients.

[Partial nephrectomy - pro robotic assisted laparoscopic operation]. / Partielle Nephrektomie - pro robotisch assistierte laparoskopische Operation.

An ever increasing use of imaging in medicine during recent years has resulted in accidental detection of an increasing number of asymptomatic small renal masses. To prevent secondary cardiovascular morbidity through loss of renal function, nephron-sparing surgery is performed for most of these masses. Minimally invasive surgery is a way to prevent postoperative complications, such aspneumonia and pain by avoiding wide incisions and by earlier mobilization of the patient. Since 2004 robotic-assisted laparoscopic nephron-sparing surgery has become a feasible alternative. It shows good functional results, less blood loss and shorter warm ischemia time compared to conventional laparoscopy. The complications can be assigned to Clavien scale grades I and II and can be treated conservatively in most cases. New surgical techniques reduce the number of tumors that cannot be operated on robotically because of size and location of the tumor. Robotic-assisted laparoscopic nephron-sparing surgery is a safe and useful alternative to conventional laparoscopy and open surgery for small renal masses.

[Incidence and long-term prognosis of papillary renal cancer. Results of a retrospective multicenter study]. / Inzidenz und Langzeitprognose des papillären Nierenzellkarzinoms. Ergebnisse einer retrospektiven Multicenterstudie.

OBJECTIVES: Papillary renal cell carcinoma (pRCC) represents the largest subgroup of non-clear-cell kidney cancer. In this retrospective multicenter study, we assessed tumor characteristics and long-term prognosis of patients with pRCC in comparison with conventional clear-cell cancer (ccRCC). METHODS: We evaluated 2,804 patients who had undergone renal surgery for pRCC or ccRCC between 1990 and 2006. The mean follow-up was 65 months. RESULTS: Both pRCC and ccRCC groups were comparable concerning age, tumor grade and the incidence of regional lymph node metastasis at diagnosis. The percentage of male patients was higher in pRCC than in ccRCC (76.0% vs. 63.6%), pRCC patients suffered less often from advanced tumors (22.3% vs. 38.1%), visceral metastasis at diagnosis (8.1% vs. 14.5%) and died less frequently due to RCC progression (16.3% vs. 29.6%). Applying multivariable analyses pRCC was found to be an independent predictor of a favorable clinical course for patients with organ-confined RCC. In contrast in advanced disease papillary histology was significantly associated with a poor prognosis and early tumour-related death. CONCLUSIONS: pRCC seem to be stratified into two different prognostic groups. Localized pRCC has a significantly better prognosis than ccRCC. In contrast, advanced pRCC is characterized by a worse clinical outcome. Whether these two different pRCC cohorts are consistent with the recently defined types 1 and 2 pRCC subtypes or are characterized by other typical genetic alterations, which would lead to a novel pRCC subclassification is currently under investigation within the German Renal Cancer Network.

[Surgical treatment for renal cell carcinoma]. / Operative Therapie des Nierenzellkarzinoms.

Renal cell carcinoma is chemoresistent and radio-therapy so that surgical tumour excision of the tumor is the only potentially curative option, either as radical nephrectomy or as nephron sparing surgery. As a result of continuously improving radiological imaging modalities, renal tumours are nowadays detected incidentally at an asymptomatic stage in up to 75 %. The ten-year cancer-specific survival for organ-confined disease (T1,T2) after R0-excision is > 90 %. Moreover, locally extending renal tumours (T3) can be treated successfully with five-year survival rates of > 65 %. In case of tumours in a single kidney or synchronous bilateral tumours, good functional and oncological long-term results can be achieved by nephron sparing surgery (imperative indication). T1 renal cell cancer (tumour size < 7 cm ) should be treated by nephron sparing surgery, even if the contralateral kidney is normal, because since this nephron-sparing approach ensures maximal renal reserve in the long term follow up. Minimally invasive techniques offer treatment also for multi-morbide patients. Which approach is to be selected depends on size and location of the tumour as well as on indication (elective or imperative), age and general health of the patient and the surgeon's preference.

Imperative and elective indications for nephron-sparing surgery for renal tumors: long-term oncological follow-up.

INTRODUCTION: Nephron-sparing surgery (NSS) is mandatory for patients with renal tumors in both kidneys or in a solitary kidney in order to preserve renal function (imperative indication). NSS has also become the gold standard (elective indication) for small unilateral renal tumors (< 4 cm) with a normal contralateral kidney. We report the oncological long-term follow-up of NSS of our own series and discuss the results of the current literature. PATIENTS AND METHODS: From 1979 until 2006, a total of 851 patients was treated at our institution by NSS. The mean tumor diameter was 3 cm (0.5-11 cm) for elective cases and 4.2 cm (1.2-11 cm) for imperative cases. The median follow-up for elective cases is 4.7 years (0.1-24.1 years) and imperative cases 8 years (0.1-25.8 years). Cancer-specific survival (CSS) and local recurrence-free survival (RFS) were estimated. RESULTS: Estimated CSS at 5 and 10 years for elective indications were 98.5% and 96.7% and for imperative indications (solitary kidney) 89.6% and 76%. RFS after 5 and 10 years for elective indications were 98.3% and 95.7%; and for imperative indications (solitary kidney) 89.4% and 79.9%. Chronic renal failure requiring haemodialysis developed after NSS in a solitary kidney in nine patients (11.2%). CONCLUSION: NSS can be performed with oncologically safe and good functional results in imperative indications. In elective indications the resectability of a tumour rather than size and location is the limiting factor.

[Elective organ-sparing surgery for renal tumors in patients with a normal contralateral kidney: long-term results]. / Elektive organerhaltende Nierentumorchirurgie bei normaler Gegenniere : Langzeitergebnisse.

Continuous improvements in radiological imaging techniques have enabled an earlier diagnosis of incidental renal tumors. The share of small renal tumors (4 cm can also be treated with nephron-sparing surgery. We report in this article our long-term oncological results of nephron-sparing surgery in patients with an elective indication.

[Imperative nephron-sparing surgery for cases of solitary kidney/bilateral tumors: long-term results]. / Imperative organerhaltende Nierentumorchirugie bei Einzelniere bzw. bilateralen Tumoren : Langzeitergebnisse.

Renal cell carcinoma is the most lethal amongst urological malignancies. Only surgical excision of the tumor offers the chance of curative therapy for patients with localized disease. Nephron-sparing surgery is mandatory for patients with renal tumors in both kidneys or in a solitary kidney in order to preserve renal function (imperative indication). Evaluation of patients with renal tumors in both kidneys or in a solitary kidney must weigh the surgical and oncological risks of nephron-sparing surgery against the morbidity of radical nephrectomy followed by hemodialysis and possibly renal transplantation. Herein we report our oncological and functional long-term results of nephron-sparing surgery in patients with an imperative indication and review the literature.