Bilateral vs unilateral laparoscopic intrafascial nerve-sparing radical prostatectomy: evaluation of surgical and functional outcomes in 457 patients.

UNLABELLED: Study Type - Therapy (case series). LEVEL OF EVIDENCE: 4. What's known on the subject? and What does the study add? Bilateral nerve-sparing radical prostatectomy still represents an issue for urologists as the indications to perform it depend oft from the personal clinical experience. Moreover, until now data concerning bilateral and unilateral laparoscopic nerve-sparing radical prostatectomy have been limited. This study states that bilateral laparoscopic intrafascial nerve-sparing technique results in superior functional outcomes when compared with unilateral nsLRP and it suggests to prefer a bilateral nerve-sparing technique in younger patients with low-risk, organ-confined prostate cancer. OBJECTIVE: To evaluate the surgical and functional outcomes in bilateral and unilateral nerve-sparing laparoscopic radical prostatectomy (nsLRP). PATIENTS AND METHODS: Between January 2005 and May 2009, 457 nsLRP were performed at our clinic. In all, 250 patients underwent a bilateral nsLRP and 207 patients underwent an unilateral nsLRP. One surgeon performed all the operations. All patients presented at biopsy a localized prostate cancer. Demographic data and perioperative and postoperative measurements and outcomes were compared. RESULTS: The operative times for bilateral nsLRP and unilateral nsLRP were 165 ± 45 min and 130 ± 25 min, respectively. The mean intra-operative blood loss was 450 ± 300 mL and 270 ± 160 mL in the bilateral and unilateral nsLRP groups with a transfusion rate of 3% and 1%, respectively (P = 0.013). Conversion to open surgery was never deemed necessary. Postoperatively, the mean Gleason Score after nsLRP and distribution of tumour stages was similar in the two groups, and the frequency of positive margins in both groups did not present any statistically significant difference. At 12 months, a complete continence was reported in 97% of patients who underwent a bilateral nsLRP and in 88% of patients of the unilateral nsLRP group. At that time, 69% in the bilateral nsLRP and 43% in the unilateral nsLRP groups reported the ability to engage in sexual intercourse. CONCLUSION: The bilateral laparoscopic intrafascial nerve-sparing technique results in superior functional outcomes with regard to urinary continence and sexual potency, when compared with unilateral nsLRP, reporting similar oncological outcomes.

Right-sided transperitoneal hand-assisted laparoscopic donor nephrectomy: is there an issue with the renal vessels?

OBJECTIVE: Short right renal vessels might complicate kidney transplantation, thus causing traction and difficulties during anastomosis. Single-center prospective comparison of right- and left-sided transperitoneal hand-assisted laparoscopic donor nephrectomy (HALDN) is presented. PATIENTS AND METHODS: Eighty-two living kidney donors underwent HALDN between 2003 and 2008. Right-sided HALDN was performed in 46 living kidney donors. The operative technique of right-sided HALDN was modified to obtain the maximum length of right renal vessels. Outcome data in donors including quality of life as well as graft outcome in recipients were prospectively collected. RESULTS: All procedures were laparoscopically completed with no conversion. Mean operative time was 127 minutes (vs. 138 minutes in left HALDN, p = 0.08). The mean warm ischemia time was 41 seconds (vs. 39 seconds in left HALDN, p = 0.23). There was no renal artery or vein thrombosis in any of the grafts. Mean blood loss was 81 mL (vs. 92 mL in left HALDN, p = 0.09). Hospital discharge was on an average of 3.6 days postoperative. Delayed graft function occurred in two recipients: one in the left group and the other in the right group. One-year graft survival rate was 95% in the left group versus 96.9% in the right group (p = 0.08). Further, no statistically significant difference in serum levels of creatinine was seen between the groups 1 year after the transplantation. CONCLUSIONS: Right HALDN is technically safe and feasible and results in convenient extension of right renal vessels to full length with no increased incidence of vascular thrombosis.

Adipocytokine: a new family of inflammatory and immunologic markers of invasiveness in major urologic surgery.

BACKGROUND: Laparoscopic surgery has been proposed to reduce surgical trauma and diminish patients' stress response. OBJECTIVE: To investigate the role of the adipocytokine, in combination with changes in other known inflammatory markers, in patients undergoing radical prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: A total of 580 patients were enrolled in this prospective study. Laparoscopic extraperitoneal radical prostatectomy (LRP) was performed in 286 patients, and open retropubic radical prostatectomy (RRP) in 294 patients. INTERVENTION: Blood samples were collected preoperatively and up to 5 d postoperatively. MEASUREMENTS: Serum concentrations of acute phase markers, interleukins (IL), and the adipocytokine leptin were measured at each time point by means of enzyme-linked immunosorbent assay. Clinical data were collected and analysed. RESULTS AND LIMITATIONS: Patients undergoing LRP had significantly lower IL-6 and adipocytokine levels at all measurement time points. However, biphasic kinetics of adipocytokine serum levels were observed during the postoperative course in all patients. LRP was associated with less adipocytokine and IL-6 release, indicating a smaller degree of surgical insult and the minimal invasive nature of this procedure. The limitation of this study was its nonrandomised design. CONCLUSIONS: Adipocytokines might serve as additional immunologic markers of invasiveness in major urologic surgery.

Multi-colour FISH on preoperative renal tumour biopsies to confirm the diagnosis of uncertain renal masses.

PURPOSE: In some cases with uncertain renal tumour lesions, it would be helpful to perform biopsies for the preoperative differential diagnosis. In our study, we evaluated the benefit of multi-colour interphase fluorescence in situ hybridization (M-FISH) on fine-needle core biopsies in uncertain renal masses. METHODS: We prospectively performed three ultrasound-guided percutaneous biopsies in 25 patients with indeterminate renal masses preoperatively. Histopathology was performed on two remaining cores samples. M-FISH was performed on one core for chromosomes 1, 2, 6, 9, 7, 17, the loci 3p24pter, and 3p13p14. After interphase FISH evaluation, we classified tumours and compared the results with histopathological findings. RESULTS: 16 were classified as renal malignancies: 14 (56%) clear cell renal cell carcinomas (RCCs), 1 papillary RCCs (4%), and 1 "adenocarcinoma" (4%). Seven patients (28%) had a benign tumour, i.e. 6 (24%) were oncocytomas and 1 was classified as leiomyoma (4%). In two cases (8%), no renal neoplasms were found. In 19 out of 21 cases (90.5%), the preoperative diagnostic fine-needle biopsy matched the final histological findings. The combination of histopathological examination and M-FISH leads to a higher (95.5 vs. 90.5%) diagnostic fidelity as histology alone. CONCLUSIONS: Ultrasound-guided percutaneous renal tumour biopsy is an accurate and safety method for the histopathologic evaluation of uncertain renal masses. The M-FISH represents a new highly sensitive and specific method to confirm histopathological classification in less than 24 h which can be used in routine laboratory diagnosis.

Management of localized prostate cancer by retropubic radical prostatectomy in patients after renal transplantation.

BACKGROUND: The study aimed to report our experience with retropubic radical prostatectomy (RRP) for treatment of localized prostate cancer in renal transplant recipients (RTR). METHODS: Data of 16 RTR who had an RRP between 2001 and 2007 were retrospectively analysed and compared to the data of 294 non-transplanted patients who were operated for RRP during the same period. Diagnostic work-up consisted of digital rectal examination, serum prostate specific antigene levels, as well as Transrectal Ultrasonography (TRUS)-guided prostate biopsy. Follow-up was obtained in all patients with a mean follow-up time of 2.1 years in RTR. RESULTS: Mean time distance to the renal transplantation at the time of RRP was 81.2 ± 19.1 months. RRP was successfully performed and tolerated in all RTR without pelvic lymph node dissection. No major complications occurred during or after the operation. There were two minor complications in transplant group (prolonged haematuria and urinary leakage). Mean operative time was 108.3 ± 3.9 min in transplant group, which was significantly longer as in non-transplanted group (89.1 ± 4.1, P < 0.05). Mean estimated intra-operative blood loss was significantly lower in transplant group (P < 0.05). In RTR, one case of positive surgical margins was present (R(1): 6.2 vs. 12.3% in non-transplanted group, P < 0.05). None of the RTR had impairment of graft function. At follow-up, no case of biochemical recurrence was observed in RTR. CONCLUSIONS: RRP is safe and feasible for management of localized prostate cancer in patients with kidney allograft being under immunosuppression. However, concern about impairment of graft function, infection and wound healing remains important.

Laparoscopic vs open retropubic intrafascial nerve-sparing radical prostatectomy: surgical and functional outcomes in 300 patients.

OBJECTIVE: To evaluate the surgical and functional outcomes in nerve-sparing laparoscopic radical prostatectomy (nsLRP) and retropubic nsRP (nsRRP). PATIENTS AND METHODS: Between January 2005 and November 2007, 150 nsLRP and 150 nsRRP were performed at our clinic. Demographic data, variables before and after surgery, and outcomes, were compared. RESULTS: The operative duration was 165 min for nsLRP and 120 min for nsRRP. Although the nsLRP group had a lower frequency of positive margins, the difference was not statistically significant. At 1 year after surgery, complete continence was reported in 97% of patients who had nsLRP and in 91% who had nsRRP (P= 0.03). At that time, 66% of patients in the nsLRP and 51% in the nsRRP group reported being able to engage in sexual intercourse (P < 0.05). There were no statistical differences in surgical trauma in both groups. CONCLUSION: Our study showed that nsLRP performed by expert surgeons results in better functional outcomes for continence and potency than for nsRRP. There was no significant difference between the surgical techniques in surgical trauma.

Huge isolated port-site recurrence after laparoscopic partial nephrectomy: a case report.

A 66-yr-old man with pain and swelling in the right flank was referred to our clinic for diagnosis. In 2005, the patient underwent a laparoscopic partial nephrectomy for renal cancer of the lower pole of the right kidney. A computed tomography scan revealed a 20-cm tumor in the right abdominal wall, resulting in a suspected diagnosis of port-site metastasis from the first laparoscopic operation. The patient underwent open surgery, which confirmed the diagnosis. After the operation, the patient recovered rapidly.

Ultrasound-guided biopsy of homogenous solid renal masses.

OBJECTIVES: We evaluated the reliability of sonographic criteria in selecting solid renal masses for percutaneous fine-needle biopsy. METHODS: In study 1 (intraoperative ultrasound study), we prospectively examined 100 consecutive patients scheduled for partial/radical nephrectomy by using two different high-resolution probes (Philips HDI 5000, CT8-4, L12-5; 4-12MHz). The main tumor was intraoperatively evaluated by B-mode and power Doppler sonography. Morphologic characteristics seen on ultrasound were categorized in (non-)homogenous and (non-)cystic renal masses and were related to findings of pathological examination. Study 1 provided the selection criteria for study 2. In study 2 (percutaneous biopsy study), under local anesthesia and with the use of an 18-G needle, we prospectively performed two to three sonographically guided percutaneous biopsies in 30 consecutive patients whose tumors appeared to be homogenous and noncystic according to the sonograph (convex array 3.5MHz, HDI 5000, C5-2 and Falcon 2101 EXL, B+K Medical). RESULTS: In the ultrasound study, only 16 (22.9%) of the 76 clear-cell carcinomas but all 9 (100%) oncocytoma appeared homogenous and noncystic on high-resolution intraoperative ultrasound. By applying these results to 30 patients of study 2 (18 men, 12 women; aged 63+/-7.7 yr, tumor size 29+/-11.3mm) who met these sonographic criteria on preoperative transabdominal ultrasound, we bioptically diagnosed 8 (26.7%) benign tumors; 25 of 30 (83.3%) patients were accurately diagnosed. Small tumors (<3cm), decreased breathing compliance, and medially located renal lesions seem to negatively influence biopsy results. CONCLUSIONS: Kidney tumors that appear noncystic and homogenous on preoperative ultrasound are more likely to be of benign origin. Ultrasound-guided percutaneous biopsy of these solid renal masses could determine renal tumor patients for whom surveillance might be an option. However, experienced and dedicated histopathologic evaluation remains crucial to observe patients with clearly benign biopsy results. All even slightly questionable biopsy findings require surgical exploration.

Radical cystectomy with ultrasound-guided partial prostatectomy for bladder cancer: a complication-preventing concept.

OBJECTIVES: Radical cystectomy has been the reference standard for the treatment of muscle-invasive bladder cancer. However, this kind of therapy does have an impact on the patient's quality of life. For this reason, we performed prostate-sparing surgery during radical cystectomy without compromising the oncologic outcome. METHODS: From December 2003 to August 2005, 31 patients with a mean age of 63.6 +/- 8 years (range 48 to 79) underwent apex-sparing radical cystoprostatectomy for invasive bladder cancer. All patients underwent transurethral biopsy in the prostatic urethra to exclude urothelial tumor and transrectal ultrasound-guided biopsy of the prostate to diagnose concomitant prostate cancer. Patients with a prostate-specific antigen level greater than 4 ng/mL were excluded from prostate-sparing cystectomy. The mean follow-up period was 12 months. RESULTS: The postoperative pathologic stage was pTis in 2 patients, pTa in 1, pT1 in 3, pT2 in 20, pT3 in 5, and pN+ in 4 patients. We found no prostate cancer on histopathologic evaluation. Except for 4 patients, no patient had deterioration of sexual function. Except for 2 patients, all patients were fully continent. CONCLUSIONS: Radical cystectomy with prostate-sparing surgery in patients with invasive bladder cancer resulted in improved continence and improved erectile function. Additionally, with apex-sparing radical cystoprostatectomy, we were able to create a wide neovesicourethral anastomosis to prevent strictures, urinary retention, and mucous retention. It is absolutely necessary that this procedure be restricted to highly selected patients.

Prediction of renal allograft rejection by urinary protein analysis using ProteinChip Arrays (surface-enhanced laser desorption/ionization time-of-flight mass spectrometry).

OBJECTIVES: To develop a noninvasive method for the detection of renal transplant rejection using ProteinChip Arrays (surface-enhanced laser desorption/ionization time-of-flight mass spectrometry). METHODS: A total of 23 urine samples were collected from 13 patients showing biopsy-proven renal allograft rejection and from 10 patients without histologic signs of rejection. All 23 patients had clinical symptoms and signs of acute allograft rejection and underwent renal biopsy. Samples were centrifuged, and supernatants were directly spotted onto the ProteinChip arrays with different chromatographic surfaces. The obtained spectra in a range from 2 to 200 kDa were subjected to bioinformatic analysis using the method of Fuzzy c-means, followed by the establishment of rule bases and evaluation using the relevance index according to Kiendl. RESULTS: Several protein peaks were identified allowing differentiation between rejection and no rejection. Using two different ProteinChip surfaces, we found two biomarkers at 25.71 kDa and 28.13 kDa that gave a diagnostic sensitivity of 90% and 93% and a specificity of 80% (SAX2) and 85% (CM10), respectively. CONCLUSIONS: Surface-enhanced laser desorption/ionization time-of-flight mass spectrometry appears to be a promising new diagnostic tool for distinguishing renal transplant patients with no rejection from those with acute rejection.

The accuracy of 250 fine needle biopsies of renal tumors.

PURPOSE: In some cases of uncertain lesions in the kidney it would be helpful to perform biopsies for preoperative histopathological evaluation. In this study we evaluated the accuracy of and the impact on tumor management of core biopsy for histopathological evaluation of small solid renal masses. MATERIALS AND METHODS: After radical or partial nephrectomy 250 renal tumor biopsies were performed in 50 patients. All biopsies were performed by 1 urologist after preparation of the kidney ex situ on back table visually guided. Formalin fixed paraffin embedded biopsies were evaluated by 1 pathologist. RESULTS: In 49 of 50 cases (98%) we could define the malignant behavior of the tumor when performing 1 central and 4 peripheral biopsies of each tumor. In 85.2% the grading was correctly defined. A benign lesion was revealed in 4 cases (8%, all oncocytoma). In renal tumors 4 cm or smaller in diameter the accuracy of 1 central and 1 peripheral biopsy each regarding definition of tumor origin, tumor grading and cell type/growth pattern was 96% and 95.5%, 84% and 84.4%, and 87.5% and 89.5%, respectively. In renal tumors more than 4 cm in diameter the accuracy was 100% and 98.1%, 85% and 94.3%, and 71.4% and 88.7%, respectively. CONCLUSIONS: Core biopsy of renal lesions is accurate enough for histopathological evaluation and determination of therapeutic procedure. Additionally, biopsy could be used for identifying benign renal lesion for observation.

Pubovaginal cutaneous fascial sling procedure for stress urinary incontinence: 10 years' experience.

OBJECTIVES: There is a considerable lack of consensus regarding indications and long-term efficacy of the many techniques for treating urinary stress incontinence. We report the long-term results of a modified pubovaginal sling procedure. METHODS: From 1989 to 1998, 129 consecutive patients underwent a pubovaginal sling by two urologists. 86 of the subjects (67%) replied to a questionnaire designed to assess the outcome of the procedure and the subjective satisfaction with the operative result. During surgery we performed a modified sling procedure using a cutaneous strip strengthened by rectus fascia and placed with almost no tension. Special care was taken not to lacerate or damage but support the urethral musculature. We routinely did an anterior vaginoplasty, and posterior vaginoplasty if necessary. RESULTS: Mean patient age was 56.8 years, mean follow-up 39 months, mean parity 2.1, previous surgery 0.4. Improvement rates were determined as follows ('Are you satisfied with the operation?'): Significantly reduced incontinence (i.e. 50-100% improvement) was found in 65.2%, slight reduction (10-40% improvement) in 15.2%, no change in 17.4% and worsening in 2.2% of all 103 cases. The majority of all complications were wound infections. CONCLUSION: Despite the considerable failure rate, the substantial improvement in the quality of life of almost two thirds of the patients during a 3-year follow-up recommends a pubovaginal sling as a treatment option for urinary incontinence.

Bladder dysfunction and end stage renal disease.

INTRODUCTION AND OBJECTIVES: Evaluation of lower urinary tract function in patients with end-stage renal disease and lower urinary tract symptoms. Patients were screened before entering a renal transplantation program. MATERIALS AND METHODS: A diagnostic work-up including urodynamics was performed on 52 patients (14 women, 38 men) suffering from renal failure due to chronic glomerulonephritis (n = 25), diabetic nephropathy (n = 15), chronic pyelonephritis/stone disease (n = 9) and polycystic kidney disease (n = 3). RESULTS: Abnormalities in lower urinary tract function of different degrees were found in 40 patients (77%). Major problems are bladder hypersensitivity (n = 31%), poor bladder compliance (38%), detrusor instability (25%) and detrusor-sphincter dyssynergia (33%). CONCLUSIONS: There is a high incidence of bladder dysfunction of different degrees in patients with renal failure. The clinical significance, especially in the long term, needs to be evaluated. However, a urodynamic assessment before renal transplantation is recommended in all patients reporting symptoms of dysfunctional voiding and/or bladder storage problems in order to avoid allograft dysfunction due to chronic bladder dysfunction and related complications. Depending on the degree of bladder dysfunction an urodynamic follow-up after transplantation is necessary. If there are no symptoms and no history of lower urinary tract dysfunction an urodynamic assessment is not necessary.

How reliable is conventional urinary cytology in post-transplant patients?

INTRODUCTION AND OBJECTIVES: Factors like cold, flushing solutions, ischemia and reperfusion may alter the microscopic appearance of transitional cells leading to falsely positive results of urinary cytology in patients after kidney transplantation. After seeing 1 patient presenting with two consecutive highly suspicious cytology specimens 3 days after transplantation and no sign of urothelial tumor at retrograde urography, we analyzed the cytological picture of transitional cells in post-transplant patients. MATERIAL AND METHODS: We investigated 31 urine specimens of 11 patients undergoing kidney transplantation preoperatively (if possible) and on days 1, 3 and 9 postoperatively. Microscopic cytology was performed by using Papanicolaou's criteria: 0 - no cytology possible (no cells), I+II - negative cytology, III - doubtful, IV - suspicious for tumor, V - tumor cells. All microscopic examinations were performed by one experienced senior pathologist. RESULTS: Mean patient age was 55.8 (+/- 17.5) years, mean residual diuresis 856 (+/- 636) ml, mean cold ischemia time 13.6 (+/- 6.4) h, mean creatinine level on day 1: 582 microM/l, day 3: 533 microM/l and day 9: 259 microM/l. None of the urinary cytology results were suspicious for malignant transformation (Papanicolaou I+II). No patient presented signs of urothelial malignancy after a mean follow-up of 3 months. CONCLUSION: Although microscopic urinary cytology may be falsely positive in 1-12% of non-transplanted patients due to urothelia atypia, inflammation or radiation/chemotherapy, the present study suggests that conventional microscopic cytology examinations in post-transplant patients are not heavily altered and do not lead to an increased false-positive rate.