PROSTATOSYMPHYSEAL FISTULA AFTER TRANSURETHRAL RESECTION OF THE PROSTATE

The formation of a urethrosymphyseal fistula is a rare complication after transurethral resection of the prostate. It may develop secondary to previous radiation therapy of the pelvis. We describe a case of spontaneous fistula formation after transurethral resection of the prostate. CASE REPORT

Pudendal nerve branch injury during radical perineal prostatectomy

We report the first case of direct surgical injury to a pudendal nerve branch during radical perineal prostatectomy. A 65-year-old patient presented with typical symptoms of a pudendal nerve lesion after radical perineal prostatectomy. As the patient did not respond to conservative treatment, surgical exploration and exeresis of the injured sensory branch of the pudendal nerve was necessary, resulting in pain improvement. Urologic surgeons should be aware of the typical symptoms after iatrogenic injury to the pudendal nerve or its branches. Early diagnosis and neurosurgical intervention are important to obtain a more favorable outcome.

Epidemiologie und �tiologie der instabilen Blase

Die instabile Blase ist eine Volkskrankheit von vergleichbarem Ausmas wie der Diabetes mellitus. Mit zunehmender Uberalterung der Gesellschaft ist von einer Aggravierung des Problems auszugehen. Die Internationale Kontinenz-Gesellschaft (ICS) hat im Jahr 2002 die Terminologie der instabilen Blase uberarbeitet und den symptomorientierten Begriff des Blasenuberaktivitatssyndroms geschaffen. Atiologisch kommen dafur eine neurogene und nichtneurogene Detrusorhyperaktivitat sowie die Detrusorhypersensitivitat in Betracht.

Radical perineal prostatectomy

Historically, perineal prostatectomy was the primary type of surgery for prostate cancer, performed for the first time by Billroth in 1867 mostly without visual control. However, Hugh Hampton Young received credit for the first perineal prostatectomy after reporting in 1905 his experience with a mostly visually controlled operation and new special instruments [1]. Different perineal routes of access to the prostate have been described, but the most commonly used route is Young’s suprasphincteric approach ventral to the external and internal sphincter ani. It was the mainstay of surgical treatment until by the mid of last century pelvic lymph node dissection became part of the procedure. Rad…

Intussuscepted ileal flap valve for revisional surgery.

SPECIFIC COMPLICATIONS OF RADICAL PERINEAL PROSTATECTOMY: A SINGLE INSTITUTION STUDY OF MORE THAN 600 CASES

Although groups at several institutions have long experience with radical perineal prostatectomy (RPP), only few reports of larger series describe associated complications, mostly without reporting management options in detail. We analyzed specific perioperative and postoperative complications of the perineal approach and management strategies thereof.The medical records of 630 patients who underwent RPP between January 1997 and May 2003 were retrospectively reviewed in regard to complications and their management. Median followup was 8 months (range 1 to 68).Major complications requiring open surgical intervention were noted in 11 patients (1.7%) for a total surgical revision rate of 2.4% …

Simplified orthotopic ileocaecal pouch (Mainz pouch) for bladder substitution

Lymph Node Metastases in Non-Muscle Invasive Bladder Cancer are Correlated With the Number of Transurethral Resections and Tumour Upstaging at Radical Cystectomy

The first paper in this section, from Mainz, attempts to identify the clinical variables associated with the prevalence of lymph node metastases in non-muscle invasive bladder cancer. The authors found that delay in cystectomy in this potentially dangerous type of tumour is to be avoided, with a higher incidence of lymph node metastases as the number of transurethral resections increases. A paper from Austria shows that in renal carcinoma the pT1 subdivision is associated with differences in conventional histopathology and expression of biomarkers. OBJECTIVE To identify clinical variables associated with the prevalence of lymph node metastases (LNMs) in patients with non-muscle invasive tra…

Intraoperative peripheral frozen sections do not significantly affect prognosis after nerve-sparing radical prostatectomy for prostate cancer

Study Type – Therapy (outcomes research) Level of Evidence 2b What’s known on the subject? and What does the study add? We hypothesized that taking intraoperative frozen section (FS) biopsies of the peripheral margins of resection during radical prostatectomy would allow an intraoperative systematic scan of resection margins. In the case of positive FS, extended resection could be performed with the aim of completely excising residual tumour, improving biochemical recurrence-free survival of patients with positive surgical margins at the inked specimen. To our knowledge, the prognostic value of achieving a negative resection status by systematically taking intraoperative FS of the periphera…

Diagnosis and surgical management of colovesical fistulas due to sigmoid diverticulitis.

Diverticular disease of the colon is the most frequent cause of colovesical fistulas. In this study we evaluated the accuracy of different diagnostic procedures for the detection of colovesical fistula and the clinical outcome in a series of 49 patients who underwent surgery for colovesical fistula due to sigmoid diverticulitis.Between 1982 and 2007, 42 men and 7 women underwent surgery for colovesical fistula due to sigmoid diverticulitis. Preoperative diagnostic procedures included the poppy seed test, abdominopelvic computerized tomography, magnetic resonance tomography of the abdomen, cystogram, retrograde colonic enema, urethrocystoscopy and colonoscopy.All patients had urinary tract i…

Complete gangrene of penis in patient with arterial vascular disease.

We present a clinical case of distal penile gangrene in a patient with peripheral vaso-occlusive disease that did not correlate with the extension of the intraoperative finding and required total penectomy. Surgical intervention at the onset of wet gangrene avoids the complication of sepsis.

Cone/wedge resection of renal cell carcinoma

Diabetes mellitus und Blasenfunktion

Steigende Pravalenz und zunehmende Patientenlebenserwartung haben beim Diabetes mellitus trotz oder gerade wegen modernster medizinischer Behandlungsmethoden zu einer Haufung urologisch relevanter Spatkomplikationen gefuhrt. Die Pravalenz der diabetischen Zystopathie (herabgesetztes Blasenfullungsgefuhl, hohe Blasenkapazitat und Blasenentleerungsstorungen) liegt bei nicht insulinpflichtigen Diabetikern bei 25% und bei insulinpflichtigen bei 48%. Ursachen sind die diabetogene autonome und peripher-somatische Polyneuropathie mit beeintrachtigter Blasensensibilitat sowie Blasenhypokontraktilitat infolge einer Uberdehnungsmyopathie des Detrusors. Aufgrund ihrer Symptomarmut erfordert die Verhut…

A curved Lowsley retractor improves manoeuvrability of the prostate during ascending radical retropubic prostatectomy

Worldwide, radical retropubic prostatectomy is the commonest surgical procedure for treating localized prostate cancer. The technique has evolved continuously over the years, yielding improved continence and potency while reducing considerably the associated complications. Simple surgical ‘tricks’ have been proposed for crucial steps, e.g. the control of the dorsal venous complex, atraumatic dissection of the neurovascular bundles (NVBs), improved visualization of the urethral stump and tailoring of the vesicourethral anastomosis [1,2].

Single-institution experience with primary tumours of the male urethra

OBJECTIVE To assess primary tumours of the urethra in males. PATIENTS AND METHODS We retrospectively reviewed our database from 1986 to 2006 for primary tumours of the male urethra; nine patients with primary tumours of the urethra were analysed and follow-up information was obtained. RESULTS Three patients had tumours of the prostatic urethra, two of which had proliferating focal inflammation and one a low-grade, superficial urothelial cancer. All patients were treated successfully with transurethral resection. Six patients had carcinoma of the bulbar or penile urethra, including two with previous local percutaneous radiotherapy for prostate cancer. All had primary surgical excision that w…

Low-frequency extracorporeal shock wave lithotripsy improves renal pelvic stone disintegration in a pig model.

OBJECTIVE To compare disintegration rates for renal stones treated by 60 vs 120 shock waves (SW)/min at the same energy settings, using standardized validated artificial stones in a pig model. MATERIALS AND METHODS Gypsum artificial stones (13 × 6 mm) were inserted into the renal pelvis on either side of 12 anaesthetized pigs by open surgery. Extracorporeal SW lithotripsy (ESWL) was applied using a new electromagnetic lithotripter (Lithoskop®, Siemens AG Healthcare, Munich, Germany) at 60 and 120 SW/min; 3000 SW were applied to each kidney with the same energy settings. Stone fragments were collected after nephrectomy, passed through calibrated test sieves, and weighed. Fragment size catego…

Predictors for clinically relevant Gleason score upgrade in patients undergoing radical prostatectomy

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Clinically relevant GSU in the prostatectomy specimen is a common phenomenon. Clinically relevant GSU occurs in one of three patients with clinically ‘very’ low-risk PCa, and a low number of biopsy cores is the key negative predictor. OBJECTIVE • To evaluate clinical predictors for Gleason score upgrade (GSU) in radical prostatectomy (RP) specimen, especially in patients with ‘very’ low risk PCA (T1c and biopsy Gleason score ≤6 and PSA <10 ng/ml and ≤2 positive biopsy cores and PSA density <0.15). Patients and Methods • 402 consecutive patients undergoing RP between 20…

Indications for preoperative prostate biopsy in patients undergoing radical cystoprostatectomy for bladder cancer.

We determined indications for preoperative prostate biopsy in patients undergoing radical cystoprostatectomy for bladder cancer.Of 316 cystoprostatectomy specimens concomitant prostate cancer was diagnosed in 21.5%. Prostate cancer was diagnosed preoperatively in 24% of cases (evident prostate cancer), 32% were suspicious for prostate cancer but no biopsy was done (suspected prostate cancer) and in 44% prostate cancer was incidental. Patients were stratified into probability groups of intermediate/high risk prostate cancer by digital rectal examination and prostate specific antigen. The incidence of unfavorable histopathology was determined in each group.Of prostate cancers 85% were organ c…

Technical advances in radical retropubic prostatectomy techniques for avoiding complications. Part II: vesico-urethral anastomosis and nerve-sparing prostatectomy

We previously reviewed different technical modifications and improvements in apical dissection in radical retropubic prostatectomy which have a considerable effect in optimizing the results. This second paper focuses on the vesico-urethral anastomosis and aspects of nerve-sparing prostatectomy.

Technical advances in radical retropubic prostatectomy techniques for avoiding complications. Part I: apical dissection

Radical retropubic prostatectomy is currently the most widely used surgical treatment for localized prostate cancer. This once cumbersome procedure has developed technically over the last 20 years, reducing dramatically the associated complications and morbidity, e.g. blood loss, incontinence and impotence. Currently the operation is safe and is the best choice for eradicating localized disease, with little loss in quality of life. However, differences in reported outcomes indicate that there is still a need for standardization and continued efforts for surgical excellence. This review focuses on the crucial steps of the procedure, in two parts: the first covers apical dissection and the se…

Nephron sparing surgery for renal cell carcinoma with normal contralateral kidney: 25 years of experience.

We report the long-term results of our consecutive series of 504 patients who underwent NSS for cancer suspicious, solid renal tumors in the presence of a normal opposite kidney at our institution since 1979.A total of 715 patients underwent NSS since 1969, including 504 for an elective indication, that is with a normal opposite kidney. Of these patients 381 (75.6%) had RCC, 123 (24.4%) had cancer suspicious benign lesions, including 53 (10.5%) with oncocytoma, 33 (6.5%) with angiomyo(lipo)ma, 23 (4.6%) with a complicated cyst and 13 (2.8%) with other benign lesions. Of the 381 patients with RCC 283 (74.3%) had clear cell, 68 (17.8%) had papillary and 30 (7.9%) had chromophobic RCC. Mean tu…

Robot-assisted ascending-descending laparoscopic nerve-sparing prostatectomy

Urokinase-plasminogen-activator receptor expression in disseminated tumour cells in the bone marrow and peripheral blood of patients with clinically localized prostate cancer.

OBJECTIVE To evaluate the expression of urokinase-plasminogen-activator receptor (uPA-R) in disseminated tumour cells (DTC) in bone marrow (BM) and peripheral blood (PB) of patients with clinically localized prostate cancer before radical prostatectomy (RP), and to assess the associations with pathological variables and prognosis. PATIENTS AND METHODS In all, 52 patients (47 with clinically localized cancer and five with benign prostatic hyperplasia, BPH, as controls) were prospectively enrolled. BM and PB samples were drawn before surgery. DTC were enriched using a commercial system, cytokeratin (CK) 8/18 was used to detect DTC, and uPA-R expression was detected by dual-immunostaining of t…

Manifestation of Congenital Urethral Diverticula in a 57-Year-Old Male

Congenital urethral diverticula are a rare finding in adult males. Most cases are diagnosed in childhood or adolescence because of voiding symptoms such as urinary dribbling. Diagnostic workup should include radiography and urethroscopy. The standard therapeutic approach is open surgical excision or endoscopic marsupialization. An unusual case of male congenital urethral diverticula that remained asymptomatic until age 57 is presented.

Perineal complications following radical perineal prostatectomy.

PURPOSE Radical perineal prostatectomy has recently attracted renewed interest and wider acceptance as an alternative route to the retropubic approach. While presumed lower morbidity is one reason for perineal prostatectomy we evaluated our patients for complications that are specific for the perineal approach. PATIENTS AND METHODS We have retrospectively analyzed 412 patients who underwent perineal prostatectomy from 10/1996 to 12/2000. Patients for the perineal approach were selected on the base of preoperative PSA (10 ng/ml) and biopsy Gleason score (< 7) without the need for simultaneous lymphadenectomy. A cystogram was performed routinely on day 7 p. o. and the catheter removed when pa…

Urethral recurrence of transitional cell carcinoma in a female patient after cystectomy and orthotopic ileal neobladder.

A 63-year-old woman presented elsewhere with a unifocal pT1, G3 transitional cell carcinoma at the bladder base in 1995. She underwent urethral sparing cystectomy and ileal neobladder. Intraoperative frozen section from the proximal urethra did not demonstrate tumor involvement. Final histological examination revealed pT1, pN2, G3 transitional cell carcinoma. Adjuvant chemotherapy was not given. In 1998 the patient had symptoms of obstructive voiding due to a 3 3 3 cm. solid mass at the neobladder-urethra anastomosis (see figure). After 6 cycles of methotrexate, vinblastine, doxorubicin and cisplatin and a transient tumor size reduction, the patient was referred to us for local tumor progre…

Ver�nderungen des Rezeptorprofils der alternden Blase

Die zukunftigen demographischen Entwicklungen stellen die Urologie durch die standig zunehmende Inzidenz altersbedingter Symptome des unteren Harntrakts (LUTS) vor eine enorme Herausforderung. Obstruktion, Instabilitat und Hypokontraktilitat sind pathophysiologische Erscheinungsformen der Altersblase und konnen durch Veranderungen des Rezeptorprofils der Blase hervorgerufen werden. Benigne Prostatahyperplasie (BPH) und Diabetes mellitus sind altersassoziierte Begleiterkrankungen, die ihrerseits wieder die Detrusorrezeptoren beeinflussen. Muskarinische Rezeptoren (M2, M3), purinerge Rezeptoren (P2X, P2Y) und adrenerge Rezeptoren (α1, β3) sind die Neurotransmitterziele der efferenten sympathi…

Transitional cell carcinoma of the renal pelvis presenting as a renal abscess.

We report on a 76-year-old woman who was diagnosed with a primary renal abscess of the left kidney. After percutaneous drainage, no clinical improvement was observed. Surgical exploration and nephrectomy were performed. The histologic evaluation revealed an unsuspected transitional cell carcinoma of the renal pelvis, which had been misinterpreted as a primary renal abscess. Malignancy must be considered as an underlying cause for the formation of a renal abscess, especially if no other predisposing factors such as diabetes mellitus or urinary stones are present.

Cancer-specific survival after radical cystectomy and standardized extended lymphadenectomy for node-positive bladder cancer: prediction by lymph node positivity and density

OBJECTIVE To investigate the associations between different overall or topographically restricted lymph node (LN) variables and cancer-specific survival (CSS) after radical cystectomy (RC) and extended LN dissection (LND) with curative intent in patients with LN-positive bladder cancer. PATIENTS AND METHODS Between 2001 and 2006, 152 patients had RC with standardized extended LND for bladder cancer with curative intent. Patients with positive LNs were stratified according to the median of the LN variables (LNs removed, number of positive LNs, LN density). CSS was related to overall and topographically restricted LN variables, e.g. different levels of LND, and relationships were tested by un…

Outcome of radical prostatectomy for incidental carcinoma of the prostate

OBJECTIVE To evaluate a contemporary series of patients with incidental prostate cancer detected by transurethral resection of the prostate (TURP) and undergoing radical prostatectomy (RP). PATIENTS AND METHODS Between 1998 and 2004, 1931 patients had TURP for obstructive voiding symptoms and suspected BPH. Incidental prostate cancer was found in 104 (5.4%); 26 of these patients had a RP. The pathological staging and treatment of these patients were reviewed retrospectively and the follow-up results obtained. RESULTS Of the 26 patients who had RP, 17 had T1a and nine had T1b carcinoma of the prostate. After RP, six (35%) in the T1a group had no residual tumour (pT0) and 11 (65%) had pT2 can…

Incidence, Clinical Symptoms and Management of Rectourethral Fistulas After Radical Prostatectomy

Rectourethral fistula is a rare but severe complication after radical prostatectomy and there is no standardized treatment. We retrospectively evaluated the incidence, symptoms and management of rectourethral fistulas based on our experience.From 1999 to 2008 we performed 2,447 radical prostatectomies. Patients in whom postoperative rectourethral fistulas developed were identified. Based on the therapeutic approach patients were categorized into group 1-conservative treatment, group 2-colostomy with or without surgical closure and group 3-immediate surgical closure without colostomy.Rectourethral fistulas developed in 13 of 2,447 patients (0.53%) after radical prostatectomy. The risk of rec…

Extraperitoneal ileal conduit

Today incontinent urinary diversion continues to be the most widely used diversion technique. A current Medicare evaluation showed that 80% of patients undergoing urinary diversion in the USA are subject to reconstruction by means of an ileal conduit [1]. In particular, older patients, patients with comorbidities, and women more frequently receive an incontinent urinary diversion [2,3]. Even with improved perioperative clinicalcare pathways, urinary diversion remains a morbid procedure. Complications are still common after urinary diversion with ≈ 27% patients re-admitted in the first 90 days after BJUI

The percentage of free prostate-specific antigen does not predict extracapsular disease in patients with clinically localized prostate cancer before radical prostatectomy

Objective To determine whether the percentage of free/total prostate-specific antigen (f/tPSA) can predict the pathological features in patients with clinically localized prostate cancer before radical prostatectomy. Patients and methods Univariate and multivariate logistic regression was used to analyse data from 171 untreated patients who underwent radical prostatectomy. Variables included the total PSA (tPSA), fPSA, f/tPSA, biopsy Gleason score, clinical stage and patient age. Results In 115 patients with pathologically organ-confined tumours ( pT2N0) the mean (sd) tPSA value was 6.9 (5.6) ng/mL; in 56 patients with extracapsular disease ( pT3pN0/N+) it was 10.2 (7.6) ng/mL; the respecti…

Single center comparison of anastomotic strictures after radical perineal and radical retropubic prostatectomy.

OBJECTIVES To analyze the incidence and management of anastomotic strictures (ASs) after radical perineal prostatectomy (RPP) and retropubic prostatectomy (RRP) and to identify possible predisposing factors. METHODS Between 1997 and 2007, we performed 866 RPP and 2052 RRP for localized prostate cancer. Median follow-up was 52 months (12-136). We analyzed preoperative serum prostate-specific antigen, prostate size, clinical and pathologic tumor stage, neoadjuvant hormone deprivation, previous transurethral resection of the prostate, transfusion requirement, anastomotic insufficiency, and acute urinary retention (AUR) and its subsequent management to identify possible predisposing factors for…

Conversion from colonic conduit into recto-sigmoid pouch (Mainz pouch II)

The Mainz Pouch II has now been used widely and found to be a valuable addition to the various types of urinary diversion. The authors from Mainz describe how a colonic conduit can be converted into a Mainz Pouch II, and the expected outcome from such a procedure. OBJECTIVE To report our long-term results of conversion from conduit conversion into a continent anal urinary diversion, as after conduit urinary diversion in childhood, some patients wish to have a later conversion to a continent diversion to avoid external appliances and to improve their quality of life. PATIENTS AND METHODS Between 1992 and 2003, 139 patients had a urinary diversion with a recto-sigmoid pouch (Mainz pouch II), …