Comparison of two different rectal spacers in prostate cancer external beam radiotherapy in terms of rectal sparing and volume consistency.

BACKGROUND AND PURPOSE: In external beam radiation (EBRT) of the prostate, the rectum is the dose-limiting organ at risk, and sparing of the anterior rectal wall is a prerequisite for safe delivery of doses beyond 70 Gy. Spatial sparing of the rectum can be achieved by introducing a spacer material into the retroprostatic space, thus separating the anterior rectal wall from the PTV. MATERIALS AND METHODS: Two spacer technologies, Spacer OAR, a polyethylene glycol gel and ProSpace, a saline inflated balloon, were compared in terms of spacer volume, stability, and dose reduction to the anterior rectum wall in 78 patients. RESULTS: Both spacer systems significantly reduced the rectum surface encompassed by the 95% isodose (gel: -35%, p<0.01; balloon -63.4%, p<0.001) compared to a control group. The balloon spacer was superior in reducing rectum dose (-27.7%, p=0.034), but exhibited an average volume loss of >50% during the full course of treatment of 37-40 fractions, while the volume of gel spacers remained fairly constant. CONCLUSIONS: In choosing between the two spacer technologies, the advantageous dose reduction of the balloon needs to be weighed up against the better volume consistency of the gel spacer with respect to the duration of hypofractionated vs normofractionated regimens.

Fluorescence Guided Targeted Pelvic Lymph Node Dissection for Intermediate and High Risk Prostate Cancer.

PURPOSE: We investigated whether visualization of the drainage system of the prostate by free indocyanine green would lead to identification of all or even more lymph node metastases detected by super-extended pelvic lymph node dissection in an intermediate and high risk patient population with prostate cancer. MATERIALS AND METHODS: A total of 38 consecutive men with intermediate or high risk prostate cancer according to the D'Amico criteria underwent fluorescence targeted pelvic lymph node dissection during laparoscopic radical prostatectomy. Super-extended pelvic lymph node dissection was added as the control. Patients with neoadjuvant hormonal therapy, macroscopic lymph node involvement or prior transurethral prostate resection were excluded from study. Statistical descriptive methods, and the chi-square test and independent t-test were used to analyze data. RESULTS: Mean patient age was 64.9 years (range 46 to 74) and mean preoperative prostate specific antigen was 13.8 ng/ml (range 0.3 to 44). A total of 23 (60.5%) and 15 cases (39.5%) were classified as intermediate and high risk, respectively. Fluorescence stained nodes were found on each side in all except 1 patient. A total of 700 lymph nodes (mean ± SD 18.4 ± 8.2 per patient) were removed, of which 531 (75% of all nodes) were fluorescence stained (mean 14 ± 8.07 per patient). Lymph node metastases were found in 15 patients (39.5%). Two patients (5.3%) had a solitary micrometastasis and 3 (7.9%) had nodes containing isolated tumor cells. Metastases were found outside the extended pelvic lymph node dissection template in 5 of 15 patients (33.3%). Three of those 5 patients attained a prostate specific antigen nadir of less than 0.1 ng/ml 6 weeks postoperatively. Fluorescence targeted pelvic lymph node dissection showed superior sensitivity and negative predictive value compared to extended and super-extended pelvic lymph node dissection to detect lymph node metastasis. CONCLUSIONS: Fluorescence targeted pelvic lymph node dissection allows for the lymphatic drainage of the prostate to be identified with great reliability. Since only the nodes draining the prostate are removed, the absolute number of removed nodes is decreased while diagnostic accuracy is increased.

A severe complication of mid-urethral tapes solved by laparoscopic tape removal and ureterocutaneostomy.

Mid-urethral tapes are largely used to manage stress urinary incontinence (SUI). In certain cases, however, this procedure results in bothersome complications that lead to complete resection. We present the case of an 85-year-old woman who presented with ongoing suprapubic pain, hematuria, vaginal bleeding and recurrent urinary tract infections. The patient had undergone a tension-free vaginal tape (TVT) procedure in 1999 and a transobturator tape (TOT) placement in 2003 for SUI. Investigations revealed a urethral stone, erosion of both TOT and TVT and an urethra-vaginal fistula. Under local anesthesia the urethral stone was removed endoscopically and the TOT removed via a vaginal approach. Due to her comorbidity, she underwent a laparoscopic intraperitoneal removal of the TVT and a definitive ureterocutaneostomy to relieve her pain, inflammation and incontinence. This is the first ever presented case of erosion of mid-urethral tapes and incontinence treated with a laparoscopic resection of the tape and ureterocutaneostomy as definitive urinary diversion.

Eraser laser enucleation of the prostate: technique and results.

BACKGROUND: Eraser, a 1318-nm diode laser, has been used for 15 yr for resection of lung metastases. It was recently introduced in urology for small kidney tumors and for the treatment of benign prostatic obstruction. OBJECTIVE: To demonstrate on video our technique of Eraser laser enucleation of the prostate (ELEP) and report our experience. DESIGN, SETTING, AND PARTICIPANTS: From June 2010 to October 2011, 43 consecutive patients were prospectively evaluated. All of them had lower urinary tract symptoms suggestive of benign prostatic obstruction and a mean prostate size of 59.9 ml (range: 34-89 ml) on transrectal ultrasound. Their mean prostate-specific antigen value was 3.4 ng/ml (range: 0.8-5.0 ng/ml); mean maximum flow rate (Q(max)), 6.9 ml/s (range: 2-11 ml/s); mean International Prostate Symptom Score (IPSS), 25.9 (range: 18-32); and mean postvoid residual (PVR), 170.5 ml (range: 60-330 ml). SURGICAL PROCEDURE: The details of the technique are shown on video. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Success was defined as patients being able to void with improved IPSS, Q(max), PVR volume, and ameliorated quality of life. RESULTS AND LIMITATIONS: The mean operating time was 67.0 ± 11.43 min. Mean serum hemoglobin was 15.1 ± 0.87 g/l before, and 14.39±0.94g/l after surgery. Mean blood loss was 115.90 ± 98.12 ml. No blood transfusions were required. All patients had their catheters removed within 2 d and were able to void spontaneously after this time. Significant improvements were noted in Q(max), quality of life, IPSS, and PVR volume from baseline to each follow-up time point. Based on the validated Clavien-Dindo system, we observed one grade 1d complication, one grade 2 complication, and one grade 3b complication. CONCLUSIONS: ELEP is a safe and reproducible method for relieving bladder outflow obstruction and lower urinary tract symptoms. Its advantages include minimal blood loss, short catheterization time, and a brief hospital stay.

Laparoscopic treatment of intrinsic endometriosis of the urinary tract and proposal of a treatment scheme for ureteral endometriosis.

OBJECTIVE: To discuss the contemporary management of urinary tract endometriosis and report our experience concerning laparoscopic treatment of intrinsic urinary tract endometriosis. METHODS: We performed a retrospective, multicenter study of data collected from March 2006 to March 2011. Ten women were referred from gynecology, seven with ureteral involvement and hydronephrosis and three with bladder involvement, for urologic management. Of the 7 women with hydronephrosis, 5 were symptomatic, with recurrent urinary tract infections or pain. All 3 women with bladder endometriosis had hematuria. All patients had previously undergone unsuccessful hormonal therapy. Ureteral endometriosis was extensively investigated and treated by laparoscopic excision of endometriotic plaques and excision of intrinsic endometriosis of the ureter. Bladder endometriosis was treated by partial cystectomy. Some patients also had endometriosis in other organs and underwent, for example, wedge resection of sigmoid colon and oophorectomy. RESULTS: The median age of the patients was 30 years (range 25-44). Seven patients with intrinsic endometriosis of the ureter all had hydronephrosis and proximal hydroureter and underwent laparoscopic ureteral segment excision and either end-to-end, spatulated uretroureterostomy or ureteral reimplatation with psoas hitch. Three patients had hematuria, and cystoscopic biopsy of the bladder lesions confirmed intrinsic endometriosis. They were treated with laparoscopic partial cystectomy. One patient with bowel symptoms also underwent laparoscopic wedge resection of the sigmoid colon and another underwent oophorectomy for a chocolate cyst. Most patients also had peritoneal endometriotic plaques excised. We did not perform simple ureterolysis. No complications were encountered. The median follow-up was 26.5 months (range 4-53), with no return of symptoms or recurrence. The annual follow-up examinations included urinalysis and ultrasonography of the urinary tract. CONCLUSION: Intrinsic endometriosis can be successfully managed with minimally invasive techniques to provide relief of symptoms, protect renal function, and prevent recurrence. We describe a classification of ureteral endometriosis determined from staging investigations.

Role of alpha/beta and gamma/delta T cells in renal ischemia-reperfusion injury.

T cells have been implicated in the pathogenesis of renal ischemia-reperfusion injury (IRI). To date existing data about the role of the T cell receptor (Tcr) are contradictory. We hypothesize that the Tcr plays a prominent role in the late phase of renal IRI. Therefore, renal IRI was induced in alpha/beta, gamma/delta T cell-deficient and wild-type mice by clamping renal pedicles for 30 min and reperfusing for 24, 48, 72, and 120 h. Serum creatinine increased equally in all three groups 24 h after ischemia but significantly improved in Tcr-deficient animals compared with wild-type controls after 72 h. A significant reduction in renal tubular injury and infiltration of CD4+ T-cells in both Tcr-deficient mice compared with wild-type controls was detected. Infiltration of alpha/beta T cells into the kidney was reduced in gamma/delta T cell-deficient mice until 72 h after ischemia. In contrast, gamma/delta T cell infiltration was equal in wild-type and alpha/beta T cell-deficient mice, suggesting an interaction between alpha/beta and gamma/delta T cells. Data from gamma/delta T cell-deficient mice were confirmed by in vivo depletion of gamma/delta T cells in C57BL/6 mice. Whereas alpha/beta T cell-deficient mice were still protected after 120 h, gamma/delta T cell-deficient mice showed a "delayed wild-type phenotype" with a dramatic increase in kidney-infiltrating alpha/beta, Tcr-expressing CD4+ T-cells. This report provides further evidence that alpha/beta T cells are major effector cells in renal IRI, whereas gamma/delta T cells play a role as mediator cells in the first 72 h of renal IRI.

Analogue of cosmological particle creation in an ion trap.

We study phonons in a dynamical chain of ions confined by a trap with a time-dependent (axial) potential strength and demonstrate that they behave in the same way as quantum fields in an expanding or contracting Universe. Based on this analogy, we present a scheme for the detection of the analogue of cosmological particle creation which should be feasible with present day technology. In order to test the quantum nature of the particle creation mechanism and to distinguish it from classical effects such as heating, we propose to measure the two-phonon amplitude via the 2nd red sideband transition and to compare it with the one-phonon amplitude (1st red sideband).