Purpose:
Open dismembering pyeloplasty has high success rates but is associated with significant morbidity and moderate cosmetic results. Aim of this study was to evaluate laparoscopic dismembering ...pyeloplasty compared with other laparoscopic techniques and open surgery in this respect.
Material and Methods:
Between September 1999 and September 2002 we performed 25 laparoscopic dismembering (LDP), 15 laparoscopic non-dismembering (LNDP) and 15 open pyeloplasties (ODP) in 55 patients. For laparoscopy two 12
mm and two 5
mm ports were used, a ureteric stent remained in place for 4 weeks. ODP was performed via a flank incision, a percutaneous ureteric stent and a nephrostomy remained for 10 days. Postoperative morbidity was assessed by visual analogue scale (VAS). Mean follow-up was 23.4±9.1 months (range 7–42) for laparoscopy vs. 21.9±8.8 (range 9–41) months for open surgery. Success was evaluated with postoperative i.v. pyelogram or diuretic nephrography.
Results:
A crossing vessel could be identified in 82.5% (33/40) with laparoscopy vs. 47.0% (7/15) in ODP. Postoperative VAS score was lower in the laparoscopic group (day 1 3.5±1.6 vs. 5.4±3.1, day 5 0.9±1.2 vs. 3.1±1.8,
p=0.001). Length of skin incision was 4.1±0.7 vs. 23.8±9.1 cm and hospital stay was 5.9±2.1 vs. 13.4±3.8 days for laparoscopy and ODP respectively. Success rate was 96.0% (24/25) for LDP, 73.3% (11/15) for LNDP and 93.4% (14/15) for ODP. Two patients with LNDP and one with ODP required re-operation. Clot retention was observed in two with LDP and one with ODP. Two abdominal wall herniations and one thromboembolism occurred with ODP.
Conclusion:
Short-term results demonstrate that dismembering laparoscopic pyeloplasty has the same success rates as open surgery but morbidity and complications are significantly decreased. Non-dismembering techniques have the least favourable results. This finding may suggest that LDP has the potential to replace open surgery as the gold standard for treatment of uretero-pelvic junction obstruction.
Abstract Objective To investigate utility and limitations of 3-Tesla diffusion-weighted (DW) magnetic resonance imaging (MRI) for differentiation of benign versus malignant renal lesions and renal ...cell carcinoma (RCC) subtypes. Materials and methods Sixty patients with 71 renal lesions underwent 3 Tesla DW-MRI of the kidney before diagnostic tissue confirmation. The images were retrospectively evaluated blinded to histology. Single-shot echo-planar imaging was used as the DW imaging technique. Apparent diffusion coefficient (ADC) values were measured and compared with histopathological characteristics. Results There were 54 malignant and 17 benign lesions, 46 lesions being small renal masses ≤4 cm. Papillary RCC lesions had lower ADC values ( p = 0.029) than other RCC subtypes (clear cell or chromophobe). Diagnostic accuracy of DW-MRI for differentiation of papillary from non-papillary RCC was 70.3% resulting in a sensitivity and specificity of 64.3% (95% CI, 35.1–87.2) and 77.1 (95% CI, 59.9–89.6%). Accuracy increased to 83.7% in small renal masses (≤4 cm diameter) and sensitivity and specificity were 75.0% and 88.5%, respectively. The ADC values did not differ significantly between benign and malignant renal lesions ( p = 0.45). Conclusions DW-MRI seems to distinguish between papillary and other subtypes of RCCs especially in small renal masses but could not differentiate between benign and malignant renal lesions. Therefore, the use of DW-MRI for preoperative differentiation of renal lesions is limited.
Objectives. To determine the efficacy of peripheral neuromodulation of the S3 region in patients with urgency-frequency syndrome due to an overactive bladder.
Methods. Fifteen patients (11 women and ...4 men) with urgency-frequency syndrome, as documented by a voiding chart, were diagnosed with overactive bladder. Pelvic pain was assessed by a visual analogue scale (VAS). Full urodynamic workup was performed before and after 12 peripheral stimulations with a 9-V monopolar generator, the so-called Stoller Afferent Nerve Stimulator (SANS). Follow-up was for a mean (SD) of 10.9 (4 to 15) months.
Results. Reduction in pain was achieved in all patients, with a decrease in VAS from a mean (SD) of 7.6 (5 to 10) to 3.1 (1 to 7) (
P = 0.00049). Seven patients (46.7%) had a complete response and were considered cured, 3 (20.0%) showed significant improvement, and 5 (33.3%) were classified as nonresponders. Urodynamic evidence of bladder instability, evident in all patients before treatment, was eliminated in 76.9% of patients. In all patients, mean (SD) total bladder capacity increased significantly from 197 (35 to 349) to 252 (78 to 384) mL (
P = 0.00795), mean (SD) volume at first bladder sensation from 95 (16 to 174) to 133 (32 to 214) mL (
P = 0.00166), and mean (SD) bladder volume at normal desire to void from 133 (27 to 217) to 188 (47 to 296) mL (
P = 0.00232). In the responding group, the mean (SD) total numbers of voids was reduced from 16.1 (9 to 24) times during the day and 4.4 (2 to 6) times during the night to 8.3 (6 to 10) and 1.4 (1 to 2) times (
P = 0.002539), respectively. No complications from treatment were observed.
Conclusions. Peripheral neuromodulation of the S3 region can successfully treat patients with urgency-frequency syndrome due to an overactive bladder.
Introduction:
Laparoscopic nephroureterectomy reduces the morbidity of surgical management of urinary tract transitional cell carcinoma (TCC), but a potentially increased risk for local tumour ...spreading was reported. We evaluated results obtained from patients undergoing a modified laparoscopic approach and open procedures in this respect.
Patients and Methods:
Between January 2000 and March 2002 we performed 19 modified laparoscopic nephroureterectomies (LNU) with open intact specimen retrieval in conjunction with open distal ureter and bladder cuff removal and 15 open standard nephroureterectomies (ONU). Staging lymphadenectomy was performed in 14/19 (73.7%) patients with LNU and in 6/15 (40.0%) with ONU. In all patients operating time, blood loss, complications, pain score (VAS) and data in respect to tumour recurrence were analysed. Mean follow-up was 22.1±9.2 (range 14–34) months for LNU and 23.1±8.8 (14–36) for ONU respectively.
Results:
In LNU and ONU pathological features were 12 pT1 vs. 10 pT1, 2 pT2 vs. 2 pT2 and 5 pT3 vs. 3 pT3, respectively. All patients had TCC and were R0 at final histology. Four patients with LNU had lymph node involvement, one in ONU. LNU had decreased operating times (
p=0.057), blood loss (
p=0.018), complications (
p=0.001) and VAS scores (
p=0.001). One tumour recurrence occurred in LNU, associated with a pT3b pN2 G3 TCC at final histology. One patient with ONU had local tumour recurrence at the site of the bladder cuff. No port-site metastasis occurred during follow-up with LNU.
Conclusion:
Improved peri-operative results and same cancer control as compared to open surgery by this modified LNU was not associated with an increased risk for tumour recurrence, since strict “non-touch” preparation, avoiding of urine spillage and intact specimen retrieval prevents tumour seeding. However, results from long term studies are still warranted to clarify this issue.
To assess the ability of apparent diffusion coefficient (ADC) measurements obtained by MRI to predict disease-specific survival (DSS) in patients with bladder cancer and compare it with established ...clinico-pathological prognostic factors.
The ethical review board approved this cross-sectional study. Patients with suspected bladder cancer receiving diagnostic 3 T diffusion-weighted imaging (DWI) of the bladder before transurethral resection of the bladder (TUR-B) or radical cystectomy were evaluated prospectively. Two independent radiologists measured ADC values in bladder cancer lesions in regions of interest. Associations between ADC values and pathological features with DSS were tested statistically. A combined model was established using artificial neuronal network (ANN) methodology.
A total of 51 patients (median age 69 years, range 41–89 years) were included. Three patients were lost to follow-up, leaving 48 patients for survival analysis. Seven patients died during the 795 months studied. ADC showed significant potential to predict DSS (p<0.05). Except for grading, all pathological features as assessed by TUR-B could predict DSS (p<0.05, respectively). The combined ANN classifier showed the highest accuracy to predict DSS (0.889, 95% confidence interval: 0.732–1, p=0.001) compared to all single parameters. ADC was the second important predictor of the ANN.
ADC measurements obtained by unenhanced MRI predicts DSS in bladder cancer patients. A combined classifier including ADC and clinico-pathological information showed high accuracy to identify patients at high risk for disease-related death.
•Apparent Diffusion Coefficient (ADC) measurements can predict disease-specific survival in bladder cancer patients before treatment.•Muscle invasiveness and vascular invasion were the most accurate clinic-pathological predictors of DSS.•An artificial neural network classifier combining clinic-pathological factors and ADC values achieved high predictive accuracy.
Morbidity and postoperative pain after extraperitoneal (E-LRPE) and transperitoneal (T-LRPE) laparoscopic radical prostatectomy was compared to open extraperitoneal radical prostatectomy (O-RPE).
...Between January 2002 and October 2003, we evaluated 41 E-LRPE, 39 T-LRPE and 41 O-RPE prospectively. All operations were performed as standard procedures by the same group of surgeons and perioperative results and complications were evaluated. Pain management was performed with tramadol 50–100
mg on demand, and no other form of anaesthesia was given. Postoperative pain was assessed daily in all patients quantifying analgesic requirement and evaluation of Visual Analogue Scale (VAS). All patients had at least a 12 month follow-up.
Mean age, prostate volume, PSA and Gleason score were comparable between all three groups (
p
>
0.05). Mean blood loss was lower with laparoscopy (189
±
140 and 290
±
254
ml), as compared to 385
±
410
ml for O-RPE (
p
=
0.002). However, mean operating times were significantly longer in L-TRPE (279
±
70
min) as compared to E-LRPE (217
±
51
min) and O-RPE (195
±
72
min) (
p
<
0.001), but E-LRPE and O-RPE showed no statistical difference (
p
=
0.1143). Average VAS score on the 1st and 5th postoperative day for E-LRPE versus T-LRPE versus O-RPE was 4.9
±
1.0 versus 7.8
±
1.5 versus 5.8
±
1.9 and 1.6
±
0.9 versus 2.3
±
1.2 versus 2.3
±
0.9 respectively, which was significant lower (
p
=
0.02) between E-LRPE versus T-LRPE (
p
<
0.001) and O-RPE (
p
=
0.008), but equal (
p
=
0.655) between T-LRPE and O-RPE since postoperative day 3. Mean tramadol analgesic consumption within the first postoperative week was 290 versus 490 versus 300
mg respectively, which was statistical different between E-LRPE and T-LRPE (
p
<
0.001), O-RPE and T-LRPE (
p
<
0.001), but not between E-LRPE and O-RPE (
p
=
0.550). Statistical analysis revealed a strong correlation of urinary leakage with increased postoperative pain (
p
=
0.029) in all groups, especially for T-LRPE (
p
=
0.007). Likewise, increased operating times (>240
min) were associated with increased post-operative pain (
p
=
0.049). Full continence defined as no pads at one year was achieved in 36/41 (88%, E-LRPE) versus 33/39 (85%, T-LRPE) versus 33/41 (81%, O-RPE), respectively (
p
=
0.2).
E-LRPE resulted in a significant subjective (VAS Score,
p
<
0.001) and objective (analgetic consumption,
p
<
0.001) pain reduction compared to T-LRPE, but only in VAS Score compared to O-RPE (
p
=
0.008). Analgetic consumption during first postoperative week was equal in E-LRPE (290
mg) and O-RPE (300
mg) (
p
=
0.550). Shorter operating times, lower urinary leakage rates, lower stricture rates and lower blood loss in E-LRPE compared to T-LRPE are mainly explained due to the long learning curve in LRPE, which we did not overcome yet, and not due to the approach (extraperitoneal versus transperitoneal).
Objectives.
Allograft stones are an uncommon clinical problem and management is mainly based on anecdotal experience, rather than analysis of larger series.
Methods.
In an 8-year period, 19 patients ...were treated for 19 renal and 3 ureteral stones. In 9 patients, stones were transplanted and 10 formed de novo stones within a mean of 28 months (range 13 to 48) after transplantation. In 4 patients, stones were removed during transplantation. Seven patients were treated with extracorporeal shock wave lithotripsy (ESWL), 3 patients had stones removed percutaneously, 1 by antegrade ureteroscopy, and 1 at the time of ureteral reimplantation. Three patients passed stones spontaneously.
Results.
In 3 of 4 patients with stones detected before transplantation, the procedure was completed successfully after endoscopic stone removal. Three of 5 patients with transplanted stones required emergency nephrostomy; 1 patient had permanent renal impairment. Three (42.9%) of 7 patients treated with ESWL needed transient nephrostomy; ultimately, all became stone free within a mean 15 days (range 10 to 40). Endoscopic stone removal always resulted in complete clearance without renal impairment. All patients were stone free during a follow-up of 29 months (range 13 to 48).
Conclusions.
Nine (47%) of 19 stones were actually transplanted. Therefore, intraoperative screening by ultrasonography with subsequent endoscopic removal is advisable. Small stones (4 mm or less) may be closely followed up, because they can pass spontaneously. ESWL is the treatment of choice for caliceal stones sized 5 to 15 mm. However, for stones greater than 15 mm or for ureteral stones, antegrade endoscopic procedures seem to be more favorable.
The aim of this prospective study was to determine morbidity and complication rate of invasive urodynamic evaluation of the lower urinary tract after transurethral multichannel pressure-flow studies.
...The study included 63 men with the clinical diagnosis of benign prostatic hyperplasia and 56 women with stress urinary incontinence. All patients underwent routine pressure-flow study as part of the urodynamic evaluation. A week later the patients returned for followup which also included a detailed interview on post-evaluation morbidity.
The overall complication rate, including urinary retention, gross hematuria, urinary tract infection and fever, was 19.0% (12 of 63) for men and 1.8% (1 of 56) for women. In men there was no statistically significant correlation between post-void residual urine or age and complication rate (p > .05). Of the men 4.8% experienced post-investigational urinary retention and all of them had significant bladder outflow obstruction. In addition, obstructed men reported a higher incidence of dysuria and pain (76.2%, 32 of 42) compared to those without obstruction (57.1%, 12 of 21), whereas only 53.6% of women reported these complaints. Of the 63 men 4 (6.2%) had significant urinary tract infections, while only 1 woman (1.8%) had infections.
Invasive urodynamic investigation is associated with a considerable rate of complications and morbidity, particularly in men with infravesical obstruction. These facts must be considered and discussed with the patient before urodynamic testing.
Purpose:
Aim of this prospective study was to determine whether patients with a higher body mass index (BMI) will benefit more from laparoscopic procedures in respect to postoperative morbidity and ...pain as compared to regular patients.
Patients and Methods:
Between September 1999 and October 2001, we performed 36 laparoscopic radical nephrectomies and 18 nephron sparing partial nephrectomies for renal cell carcinoma and 6 nephrectomies for benign disease (group 1,
n=60). In addition, we performed 24 open radical nephrectomies and 18 nephron spearing interventions for renal cell carcinoma (group 2,
n=42). Mean age was 59±17.9 years and average BMI was 27.1±3.3
kg/m
2 in the entire group. All techniques were evaluated for intraoperative results and complications. Postoperative morbidity was assessed in all patients by quantifying pain medication and by daily evaluation of Visual Analogue Scale (VAS).
Results:
Mean hospitalisation time in group 1 as compared to group 2 was 10.1 days versus 5.4 days, average operating time was 273 minutes versus 187 minutes, mean length of skin incision was 7.2
cm versus 30.8
cm. Overall analgesic consumption was lower in the laparoscopic group (190
mg versus 590
mg,
p<0.001), in patients with a BMI >28
kg/m
2 the difference was even more pronounced (160
mg versus 210
mg,
p=0.032). In group 1, patients with a BMI >28
kg/m
2 had significantly less pain on the first and fourth postoperative day in a linear regression analysis (VAS1=10.714−0.218 BMI;
r=0.688 (
p<0.001) and VAS4=3.98−0.09 BMI,
r=0.519 (
p<0.001), respectively). In group 1, 3/60 (5.0%) and in group 2, 5/42 (11.9%) complications occurred, no difference was found in respect to a high BMI (
p=0.411).
Conclusion:
Patients with a higher BMI (cut-off >28
kg/m
2) benefit more from laparoscopy than slim patients in respect to postoperative pain and morbidity but do not experience more complications. Consequently, reluctance to perform laparoscopic procedures in patients with a higher BMI is no longer justified.
To evaluate the detection rate of prostate cancer (PCa) after magnetic resonance-guided biopsy (MRGB); to monitor the patient cohort with negative MRGB results and to compare our own results with ...other reports in the current literature.
A group of 41 patients was included in this IRB-approved study and subjected to combined MRI and MRGB. MRGB was performed in a closed 1.5 T MR unit and the needle was inserted rectally. The follow-up period ranged between 12 and 62 months (mean 3.1 years). To compare the results with the literature, a systematic literature search was performed. Eighteen publications were evaluated.
The cancer-suspicious regions were punctured successfully in all cases. PCa was detected in eleven patients (26.9 %) who were all clinically significant. MRGB showed a benign histology in the remaining 30 patients. In the follow-up (mean 3.1 years) of patients with benign histology, no new PCa was diagnosed. The missed cancer rate during follow-up was 0.0 % in our study.
MRGB is effective for the detection of clinically significant cancer, and this is in accordance with the recent literature. In the follow-up of patients with benign histology, no new PCa was discovered. Although the probability of developing PCa after negative MRGB is very low, active surveillance is reasonable.