[Minimally invasive vs. open partial nephrectomy : Perioperative success and complication rates]. / Minimal-invasive vs. offene Nierenteilresektionen : Perioperative Erfolgs- und Komplikationsraten.

BACKGROUND: Solid renal masses are increasingly treated with nephron-sparing surgery. As in other uro-oncological surgical techniques, minimally invasive and robotic-assisted techniques are becoming increasingly popular. OBJECTIVES: The perioperative results from minimally invasive nephron-sparing surgery versus open surgery were retrospectively compared. MATERIALS AND METHODS: In our single center retrospective study, all patients who underwent nephron-sparing tumor excision between 2006 and 2016 were divided into two groups (group O = open approach and group M = minimally invasive approach). The (pre-)operative data, complications, and change in renal function were compared. Trifecta criteria (R0, no perioperative complications, ischemia ≤25 min) were used to determine success rates. RESULTS: Of 329 patients, 310 were included for analysis (group O 123, group M 187). Patients in group O had significantly worse ASA score but comparable Charlson Index and significantly more pT3/4 tumors but equal PADUA-score when compared with group M. Otherwise, preoperative patient and tumor characteristics were comparable. Patients in group M had significantly shorter hospital stays (p < 0.001) and lower transfusion rates (p < 0.05). Trifecta criteria were more frequently met in group M than in O (M: 66.8% vs. 0: 49.6%; p < 0.001). Both major and minor complications were lower in group M (major: 10.7% vs 17.1%; minor: 13.9% vs. 26.0%; p < 0.05). Preservation of renal function was comparable in both groups. R0 rates did not differ significantly between groups (M: 97.8% vs O: 97.5%). Surgical procedure times were significantly longer in group M (p < 0.001; mean 30 min). CONCLUSIONS: Minimally invasive, robotic assisted partial nephrectomy also proved to be successful in complex cases. In all aspects studied, the minimally invasive approach was shown to be at least equivalent to the open approach.

Functional Outcome of Completely Intracorporeal Robotic Ileal Ureteric Replacement.

OBJECTIVE: To assess perioperative, clinical, and functional outcomes following completely robotic ileal ureter. METHODS: We retrospectively reviewed 7 consecutive patients undergoing completely intracorporeal ileal ureteric replacement between November 2015 and May 2017. One patient had a solitary kidney. A 4-arm technique was used. In 5 patients, additional psoas hitch procedure was performed. Patients had retrograde filling and removal of the ileal stent and transurethral catheter at an average of 14 days postoperatively. Renal ultrasonography, serum analysis, and diuretic renography were performed at follow-up 3 months postoperatively. RESULTS: Mean operative time was 328 ± 66.3 minutes and median estimated blood loss was 100 mL (range 50-200); mean length of the ileal substitute was 20.4 cm (range 18-24). No case was converted to open surgery. In 1 patient, there was a prolonged insufficiency of the pyeloileal anastomosis, requiring prolonged stenting. Apart from that, there were no major complications and no open surgical or endoscopic reinterventions. On 3-month follow-up, all patients presented symptom-free, with no signs of obstruction on ultrasound and significantly improved glomerular filtration rate, creatinine levels, and differential renal function (P = .02, 0.03, and 0.046, respectively). Five patients had a diuretic halftime <10 minutes, 2 had a halftime between 10 and 20 minutes. CONCLUSION: Completely intracorporeal robotic ileal ureteric replacement results in full functional restoration of the upper tract in cases of long defects of the mid and upper ureter.

[Community acquired urinary tract infections - association with risk factors : Changes in causative organisms and resistance over time]. / Ambulant erworbene Harnwegsinfektionen ­ Assoziation zu Risikofaktoren : Keimspektrum und Resistenzlage im zeitlichen Verlauf.

BACKGROUND: Published studies on community-acquired urinary tract infections (UTI) often do not link microbiological findings with clinical risk factors and patient data. MATERIALS AND METHODS: We retrospectively correlated clinical findings of all patients with UTI of a urological outpatient clinic with the respective microbiological analysis of their urine samples over 2 periods of time: (A: 2005-2006 and B: 2011-2012). Patients were stratified to the following risk groups: uncomplicated cystitis, diabetes mellitus type 2, nursing home resident, prostatitis/epidydimitis, permanent catheter. RESULTS: The incidence of Escherichia coli (p < 0.001) and proteus (p < 0.001) significantly decreased from period A to B, while enterococci (p = 0.003) and staphylococci (p < 0.001) significantly increased. Antibiotic sensitivity to fosfomycin (p < 0.001), doxycycline (p < 0.001), nitrofurantoin (p < 0.001), and nitroxoline increased (p < 0. 001) and sensitivity to amoxicillin (p < 0.001) and gentamicin decreased (p < 0.001). Patients with a permanent catheter had significantly poorer sensitivity rates (50% and less) for almost all antibiotics tested compared to the overall group. The risk of a UTI with 3MRGN or MRSA bacteria was significantly higher for catheter carriers and nursing home residents. CONCLUSIONS: Empiric antibiotic first-line therapy with nitrofurantoin and fosfomycin for uncomplicated community acquired UTIs are well indicated in conformity with guidelines. The accumulation of multiresistant pathogens in patients with a permanent bladder catheter requires restrictive use of any permanent catheter drainage.

[Follow-up care - consequences of urinary diversion after bladder cancer]. / Nachsorge - Konsequenzen der Harnableitung nach Harnblasenkarzinom.

Radical cystectomy is the standard of care for muscle-invasive bladder cancer. Continent urinary diversions utilizing both small and large bowel are becoming more prominent: therefore, the postoperative follow-up has to focus on different aspects. In the first instance after radical cystectomy functional issues with respect to potential stenosis, post-void residual urine and micturition disorders are important. In the early phase the oncological follow-up aims to detect local, urethral and systemic recurrences and new data show the importance of the first 3 years after surgery. Long-term follow-up focuses on metabolic aspects, such as cobalamin or bile acid deficits, acidosis and disorders of calcium and bone metabolism. Follow-up care should consider specific complications of different types of urinary diversions; however to date standardized follow-up guidelines are lacking.

[Transposition of the stoma in ileal conduits: the "trouble shooting" technique for stomal complications]. / Transposition des Stomas beim Ileum-Conduit "trouble shooting" Technik bei Stomakomplikationen.

OBJECTIVE: To investigate stoma-related complications in ileal conduits we present a series of 4 patients in whom we performed a transposition of the conduit to the contralateral side as a surgical solution for large parastomal hernias. PATIENTS AND METHODS: 4 patients presented between 1998 and 2009 with large parastomal hernias, all in the right hemi-abdomen. A transposition to the contralateral side was carried out. RESULTS: The postoperative course was uneventful in all patients. After a median follow-up of 30 months all patients were free of complaints regarding the new stoma site. No patient presented with peristomal ulcerations or a recurrent hernia during the entire time of follow-up. CONCLUSION: The transposition of an existing conduit and the creation of a new contralateral ostomy site is an effective solution for patients suffering from severe local ostomy complications that are not manageable otherwise.

[Follow-up after radical nephrectomy and nephron sparing surgery of kidney tumors]. / Uroonkologische Nachsorge nach radikaler Nephrektomie und nierenerhaltender Tumorresektion.

Renal cell carcinoma represents more than 90 % of all malignant kidney tumors. International guidelines for follow-up examinations after surgery for kidney tumors are still incomplete. New challenges are arising because of growing use of nephron sparing surgery. According to well-known prognosticators risk-adapted follow-up strategies may be established that are stratified into 3 risk groups.

[Follow-up after surgical replacement of the urinary bladder (urinary diversion)]. / Nachsorge nach Blasenersatzoperationen.

Surgical replacement of the urinary bladder is usually necessary after radical cystectomy for muscle invasive bladder cancer. Besides uro-oncological follow-up (local, urethral, and systemic recurrence; tumor in the upper tract) functional follow-up of the urinary diversion is indicated. Guidelines are still scarce. Long contact time and large surface area in continent pouches made from long intestinal segments lead to absorption of contents of urine and thus to acidosis and imbalances in serum electrolytes. Compensation depends on renal function. Exclusion of long ileal segments out of the intestinal passage may lead to malabsorption of Vitamin B12 and bile acids. 30 % and more of long-term survivors with continent pouches take Vitamin B12 and sodium bicarbonate. Special attention has to be paid to obstruction of the upper urinary tract, total renal function and to secondary malignancy in the bladder substitute. For the latter, sigma-rectum pouches, augmentation cystoplasties and continent pouches with incorporation of colonic segments are at special risk. Functional follow-up affords good understanding of the specific complications of the different types of urinary diversions.

Ureteral substitution with reconfigured colon: long-term followup.

PURPOSE: Long defects in the mid and upper ureter are not amenable to end-to-end reconstruction. Therefore, we present the long-term results of our technique with reconfigured colon segments. MATERIALS AND METHODS: Between June 1998 and July 2008, 14 patients underwent ureteral replacement at our institution with reconfigured colon. In 4 patients the substitute was anastomosed to the skin as a modified colon conduit. In 10 patients it was interposed with anastomosis to the ureter in 4, to the bladder in 5 and to the afferent loop of an ileal bladder substitute in 1. RESULTS: At a median followup of 52.4 months (range 7 to 136) excellent renal function was confirmed in 10 of 14 patients. Now at a median followup of 95.8 months (range 38 to 136) 6 patients are alive, all without an indwelling stent and with no sign of obstruction of the ureteral replacement. Metabolic disorders, mucus obstruction and stricture or adhesive ileus were absent during followup. In this series death was unrelated to the procedure. In 7 patients 11 specific reinterventions were necessary including 4 cases of prolonged stenting after surgery, 3 which required secondary drainage, 3 cases of urinary tract infection at 4 weeks and 3 and 112 months, and 1 acute bowel obstruction due to peritoneal carcinosis. CONCLUSIONS: Reconfigured colon segments can be used successfully to replace long ureteral defects. The advantages are use in patients with impaired renal function and lack of small intestine, proximity of the colon to the ureter, optimal cross-sectional diameter of the graft and less intraperitoneal surgical trauma than with ileal substitutes.

[Carcinoid tumor of the testis]. / Insuläres Karzinoid des Hodens.

A 69-year-old man presented with a 2.4 cm painless mass in his right testis. Inguinal orchiectomy was performed. Histologically a carcinoid tumor of the testis was diagnosed. These neuroendocrine, noninvasive tumors are very rare, representing 0.23% of all testicular neoplasms. In 10% these tumors are associated with carcinoid syndrome and in 20% with metastatic disease.

[Are there indications for organ-preserving tumor resection in urothelial cancers of the upper urinary tract?]. / Gibt es Indikationen zur organerhaltenden Tumorresektion bei Urothelkarzinomen des oberen Harntraktes?

PURPOSE: Identification of prognostic factors for tumor recurrence in nephronsparing surgery and tumor progression after organ-preserving surgery. MATERIAL AND METHODS: From June 1989 to February 2003, 43 patients (47 nephron units) underwent organ-preserving surgery or the upper urinary tract because of urothelial carcinoma, with 26 (60.5 %) having an elective indication (healthy contralateral kidney). RESULTS: The mean follow-up was 39.2 months with a range of 10.6 to 168.3 months. Ipsilateral recurrences occurred in 13 (27.6 %) of reno-ureteral units. Recurrences were significantly more common for tumors located in the renal pelvis or opposite the ureteral origin (p = 0.018). Tumor progression occurred in 8 of 43 patients (18.6 %) and significantly correlated with the T- and G-stage of the primary tumor (p = 0.006 and p = 0.002). Of the 47 conservatively treated reno-ureteral units, 38 (80.8 %) could be preserved. CONCLUSION: Organ-preserving resection of the urothelial carcinoma of the upper urinary tract is an alternative in some patients with well-differentiated superficial tumors. A follow-up for life and a good patient compliance are necessary. Tumors of the renal pelvis have a significantly higher recurrence rate than ureteral tumors. Poorly differentiated tumors should undergo organ-preserving surgery only if the goal is palliation and in patients with solitary kidney after intensive consultation about the high risk of invasive recurrences and the development of metastases.

Preputial flap for primary closure after excision of tumors on the glans penis.

In patients with large defects of the glans penis consequent to organ-preserving tumor excision, we describe a vascularized flap formed from the outer preputial leaf for primary defect coverage. We have used this successfully in 3 men in whom both erections and penile length have been preserved.

Reconstruction of ureter with transverse retubularized colon segments.

PURPOSE: We present a technique in which colon segments are reconfigured as substitutes for ureteral defects. MATERIALS AND METHODS: Via a flank incision a 3 cm. segment was obtained from the ascending or descending colon and reconfigured into a well vascularized tube. In 2 patients a single retubularized colon segment was interposed into an extensive defect of the upper and mid ureter, respectively. In an additional 2 patients 2 combined anastomosed reconfigured colon segments were used for pyelo-colo-cutaneostomy. RESULTS: At a followup of 9 to 27 months (mean 15), no complications related to the reconfigured colon segments were noted. One patient died of progressive disease 9 months postoperatively but with no evidence of ureteral substitute malfunction. CONCLUSIONS: Reconfigured colon segments may be used successfully to reconstruct extensive ureteral defects. Access is via a flank or pararectal incision and intraperitoneal surgery is minimal. The colon segments are obtained immediately proximal to the ureteral defect, necessitating little mobilization of the mesenteric pedicle. Metabolic consequences should be absent or low since only minimal amounts of intestine are isolated. In patients with renal insufficiency or a history of irradiation this technique may be superior to the use of ileum.

A tool for self-dilatation of distal urethral strictures.

We propose the use of a catheter stopper with a smooth tip as a tool for the dilatation of distal urethral strictures. This allows for self-dilatation by the patient himself or by non-professionals involved in daily care at regular intervals. The method was successfully used in 2 patients.