De novo Renal Transplantation after Kaposi Sarcoma: Favorable Outcome in a Patient Receiving Sirolimus and Mycophenolate-Based Immunosuppression

Immunosuppressive treatment increases the risk of infection and malignancy in organ transplant recipients. We report on a 42-year-old male renal transplant recipient who lost his first graft after reduction of immunosuppressive treatment due to Kaposi sarcoma and who successfully underwent a second renal transplant 10 years later. The patient's current treatment consists of low-dose prednisone, and the two antiproliferative immunosuppressants mycophenolate mofetil and rapamycin. 4.5 years after his second transplant, the serum creatinine is 1 mg/dl and the patient has no signs of recurrent disease.

[What is most important is what comes across : Urological guidelines from the target group's point of view]

BACKGROUND

Guidelines are developed to improve the quality of patient care. The effect of German urologic guidelines has not been evaluated so far. Therefore, we aimed to systematically investigate the acceptance, use, and quality of the published guidelines from a user's perspective.

METHODS

A link to an online questionnaire concerning use and barriers to the application of guidelines was distributed via e-mail by the German Society of Urology (DGU). German urologists' opinions on differences in national guideline quality were evaluated regarding prostate cancer (PCA), bladder cancer, germ cell tumors (GCT), renal cell carcinomas, and erectile dysfunction.

RESULTS

Four hundred sixty-seven German urologists participated. More than 90% of the participants considered guidelines to be helpful. The Internet as the main tool for guideline distribution was favored by 28.4%, followed by publication in Urologe A. The main barrier to guideline usage was attributed to the lack of up-to date clinical data. Guidelines for GCT scored best in all quality categories and reached the highest level of use (65.8%), and 40.5% of participating urologists considered the additional establishment of comprehensive care centers for GCT as more effective for quality improvement than guideline development alone. For the other urologic tumors, especially PCA, guideline development was favored as a tool for quality improvement.

CONCLUSION

More than 90% of participating urologists accept clinical guidelines as useful instruments in clinical practice and for therapeutic decisions. Our results should be integrated into guideline dissemination and implementation strategies in order to achieve a higher degree of treatment conformation to guidelines.

[New biomarkers and application of multivariate models for detection of prostate cancer]

The specificity of PSA has been enhanced by using molecular forms of PSA and free PSA (fPSA) such as percent free PSA (%fPSA), proPSA, intact PSA or BPHA and / or new serum markers. Most of these promising new serum markers like EPCA2 or ANXA3 still lack confirmation of the outstanding initial results or show only marginally enhanced specificity at high sensitivity levels. PCA3, TMPRSS2-ERG, and other analytes in urine collected after digital rectal examination with application of mild digital pressure have the potential to preferentially detect aggressive PCa and to decrease the number of unnecessary repeat biopsies. The combination of these new urinary markers with new and established serum markers seems to be most promising to further increase specificity of tPSA. Multivariate models, e. g., artificial neural networks (ANN) or logistic regression (LR) based nomograms have recently been performed by incorporating these new markers in several studies. There is generally an advantage to include the new markers and clinical data as additional parameters to PSA and %fPSA within ANN and LR models. Results of these studies and also unexpected pitfalls are discussed in this review.

Laparoscopic donor nephrectomy

Laparoscopic live donor nephrectomy (LDN) has removed disincentives of potential donors and may bear the potential to increase kidney donation. Multiple modifications have been made to abbreviate the learning curve while at the same time guarantee the highest possible level of medical quality for donor and recipient. We reviewed the literature for the evolution of the different LDN techniques and their impact on donor, graft and operating surgeon, including the subtleties of different surgical accesses, vessel handling and organ extraction. We performed a literature search (PubMed, DIMDI, medline) to evaluate the development of the LDN techniques from 1995 to 2003. Today more than 200 centres worldwide perform LDN. Hand-assistance has led to a spread of LDN. Studies comparing open and hand-assisted LDN show a reduction of operating and warm ischaemia times for the hand-assisted LDN. Different surgical access sites (trans- or retroperitoneal), different vessel dissection approaches, donor organ delivery techniques, delivery sites and variations of hand-assistance techniques reflect the evolution of LDN. Proper techniques and their combination for the consecutive surgical steps minimize both warm ischaemia time and operating time while offering the donor a safe minimally invasive laparoscopic procedure. LDN has breathed new life into the moribund field of living kidney donation. Within a few years LDN could become the standard approach in living kidney donation. Surgeons working in this field must be trained thoroughly and well acquainted with the subtleties of the different LDN techniques and their respective advantages and disadvantages.

Clinical hyperthermia of prostate cancer using magnetic nanoparticles: Presentation of a new interstitial technique

The aim of this pilot study was to evaluate whether the technique of magnetic fluid hyperthermia can be used for minimally invasive treatment of prostate cancer. This paper presents the first clinical application of interstitial hyperthermia using magnetic nanoparticles in locally recurrent prostate cancer. Treatment planning was carried out using computerized tomography (CT) of the prostate. Based on the individual anatomy of the prostate and the estimated specific absorption rate (SAR) of magnetic fluids in prostatic tissue, the number and position of magnetic fluid depots required for sufficient heat deposition was calculated while rectum and urethra were spared. Nanoparticle suspensions were injected transperineally into the prostate under transrectal ultrasound and flouroscopy guidance. Treatments were delivered in the first magnetic field applicator for use in humans, using an alternating current magnetic field with a frequency of 100 kHz and variable field strength (0-18 kA m(-1)). Invasive thermometry of the prostate was carried out in the first and last of six weekly hyperthermia sessions of 60 min duration. CT-scans of the prostate were repeated following the first and last hyperthermia treatment to document magnetic nanoparticle distribution and the position of the thermometry probes in the prostate. Nanoparticles were retained in the prostate during the treatment interval of 6 weeks. Using appropriate software (AMIRA), a non-invasive estimation of temperature values in the prostate, based on intra-tumoural distribution of magnetic nanoparticles, can be performed and correlated with invasively measured intra-prostatic temperatures. Using a specially designed cooling device, treatment was well tolerated without anaesthesia. In the first patient treated, maximum and minimum intra-prostatic temperatures measured at a field strength of 4.0-5.0 kA m(-1) were 48.5 degrees C and 40.0 degrees C during the 1st treatment and 42.5 degrees C and 39.4 degrees C during the 6th treatment, respectively. These first clinical experiences prompted us to initiate a phase I study to evaluate feasibility, toxicity and quality of life during hyperthermia using magnetic nanoparticles in patients with biopsy-proven local recurrence of prostate cancer following radiotherapy with curative intent. To the authors' knowledge, this is the first report on clinical application of interstitial hyperthermia using magnetic nanoparticles in the treatment of human cancer.

[New developments in minimally invasive urology: NOTES (Natural Orifice Transluminal Endoscopic Surgery) and LESS (Laparo-Endoscopic Single-Site Surgery) in urology]

Laparoscopic surgery in urology has undergone a rapid development in the last decade. In general, many studies have underlined the benefits of laparoscopy in urology. The latest innovations in the field of minimally invasive urology are aimed at a further reduction of the morbidity associated with minimally invasive surgery. Two novel innovations are currently being developed, natural orifice transluminal endoscopic surgery (NOTES), whereby intraperitoneal access is gained through natural orifices and laparo-endoscopic single-site surgery (LESS), wherein one surgical access is used both for introducing instruments and for retrieving the specimen. Many case reports and small patient series have been published rapidly in the past two years. However, comparative randomised studies to conventional laparoscopy or open surgery do not yet exist. LESS and NOTES are two new innovative approaches, whereby feasibility studies not only for simple nephrectomy but also for complex procedures like partial nephrectomy, radical prostatectomy, ureterocystoneostomy have been published. In the next few years, comparative studies between these techniques and conventional laparoscopy can be expected.

Fast-track surgery in laparoscopic radical prostatectomy: basic principles

Fast-track surgery describes innovative treatment concepts ensuring a faster convalescence phase. The aim of this study was to allow hospital discharge 3 days after surgery without additional complications in patients receiving LRPE for localized prostate cancer. Twenty-five patients each were randomized in the study groups to verify if a fast-track regimen could be transferred into clinical routine. The perioperative data, early complications, hospital stay as well as readmission rate were analyzed. The mean postoperative stay was 3.6 days in the fast-track group versus 6.7 days in the conventional group. The overall complications were significantly less in the fast-track procedure. The readmission rate was low and not significant. Patients receiving an LRPE benefit from a suitable fast-track concept. The postoperative hospital stay could be shortened nearly by half with a significantly decreased overall complication rate. Thus, fast-track concepts might contribute to saving resources in the long term. However, more evidence based on larger prospective trials is needed to achieve optimal quality of life for patients perioperatively.

[Ten years of laparoscopic living kidney donation. From an extravagant to a routine procedure]

Ten years ago the first laparoscopic living donor nephrectomy (LDN) was performed. Today, LDN is a routine operation in many US-American transplantation centers and an increasing number of centers in Europe are practicing LDN. In this article the different aspects of LDN for donor, kidney, recipient and operating surgeon are evaluated. We performed a literature research concerning LDN and the different aspects. Our own experience, as the largest LDN center in Germany, is part of the evaluation. Laparoscopic extraction of a kidney from a living donor is as safe for the donor as the open approach. At the same time, LDN offers multiple advantages like reduced pain and shorter convalescence. For the donated kidney and the recipient no disadvantages occur from the laparoscopic technique, as long as special intra- and perioperative demands are met. For the operating surgeon multiple developments have expanded the technical armentarium. LDN is safe for donor, recipient and kidney. Central issue of an optimal LDN is sufficient experience with laparoscopic urological techniques.

Dental findings and rehabilitation in familial osteodysplasia (Anderson type): a case report

Familial osteodysplasia is a disorder of osteogenesis with an autosomal recessive pattern of inheritance which predominantly affects facial bones. No recent case had been reported, particularly from a dental point of view since the syndrome was first described by Anderson et al (JAMA 1972;220:1687-93). A 23-year-old male with familial osteodysplasia was presented in maxillofacial and dental aspects with clinical and radiological manifestations including malocclusion, abnormal teeth alignment, impacted teeth, shape disturbances including uncompleted coronal formation, root shortening with bulbous form, high angled mandible and elongation of the corpus of mandible. Recognition of the syndromal features prior to any dental intervention is of paramount importance because of increased inclination to spontaneous mandibular fractures. Hence, no surgical intervention was performed for impacted teeth. Following the extractions of severely mobile teeth, a definitive restoration was fabricated as distal-extension removable partial dentures with conus crown telescopic system. The aesthetic and functional outcome was satisfactory for the patient. In conclusion, dentists appear to play an important role in the recognition of familial osteodysplasia, based on maxillofacial and dentoalveolar findings. Awareness of the syndromal features, especially of spontaneous fractures, would detect the limitations for dental interventions and treatment planning.

Nierentransplantation im Kindes- und Jugendalter

The reasons for end-stage renal disease in pediatric patients differ from adults. The therapy of choice is renal transplantation. A total of 117 children and adolescents were treated with renal transplantation in 2003 in Germany. Immunosuppressive therapy and related comorbidities are the main problems in pediatric patients. The following article provides a summary of transplantation in children, preparation, and follow-up.

Clinical hyperthermia of prostate cancer using magnetic nanoparticles: presentation of a new interstitial technique

The aim of this pilot study was to evaluate whether the technique of magnetic fluid hyperthermia can be used for minimally invasive treatment of prostate cancer. This paper presents the first clinical application of interstitial hyperthermia using magnetic nanoparticles in locally recurrent prostate cancer. Treatment planning was carried out using computerized tomography (CT) of the prostate. Based on the individual anatomy of the prostate and the estimated specific absorption rate (SAR) of magnetic fluids in prostatic tissue, the number and position of magnetic fluid depots required for sufficient heat deposition was calculated while rectum and urethra were spared. Nanoparticle suspensions were injected transperineally into the prostate under transrectal ultrasound and flouroscopy guidance. Treatments were delivered in the first magnetic field applicator for use in humans, using an alternating current magnetic field with a frequency of 100 kHz and variable field strength (0-18 kA m(-1)). Invasive thermometry of the prostate was carried out in the first and last of six weekly hyperthermia sessions of 60 min duration. CT-scans of the prostate were repeated following the first and last hyperthermia treatment to document magnetic nanoparticle distribution and the position of the thermometry probes in the prostate. Nanoparticles were retained in the prostate during the treatment interval of 6 weeks. Using appropriate software (AMIRA), a non-invasive estimation of temperature values in the prostate, based on intra-tumoural distribution of magnetic nanoparticles, can be performed and correlated with invasively measured intra-prostatic temperatures. Using a specially designed cooling device, treatment was well tolerated without anaesthesia. In the first patient treated, maximum and minimum intra-prostatic temperatures measured at a field strength of 4.0-5.0 kA m(-1) were 48.5 degrees C and 40.0 degrees C during the 1st treatment and 42.5 degrees C and 39.4 degrees C during the 6th treatment, respectively. These first clinical experiences prompted us to initiate a phase I study to evaluate feasibility, toxicity and quality of life during hyperthermia using magnetic nanoparticles in patients with biopsy-proven local recurrence of prostate cancer following radiotherapy with curative intent. To the authors' knowledge, this is the first report on clinical application of interstitial hyperthermia using magnetic nanoparticles in the treatment of human cancer.

Laparoscopic versus Open Donor Nephrectomy in Germany: Impact on Donor Health-Related Quality of Life and Willingness to Donate

INTRODUCTION

Laparoscopic living donor nephrectomy (LDN) offers multiple advantages to the donor. Since 1999 LDN has become the only surgical approach for living kidney donation in our department. To our knowledge a donor health-related quality of life (QoL) has not yet been performed with standardized and validated questionnaires to compare laparoscopic with open nephrectomy. We therefore performed a study with two questionnaires (SF-36/GBB-24) and one set of open questions for all donors in our department.

METHODS

Questionnaires were sent out to all donors between 1983 and 2001 with at least a 1-year follow-up. To exclude a bias a maximum response rate was sought; donors who did not answer were recontacted as well as their recipients or their physicians to motivate them for participation.

RESULTS

The response rate was (89.8%). Except for less limb pain in the laparoscopy group, no difference could be detected for donors QoL with respect to the surgical method. Willingness to donate again was not affected by the surgical method. Nevertheless if asked again today, most donors want laparoscopic kidney retrieval.

CONCLUSIONS

Donors health-related QoL is not affected by the surgical method when queried retrospectively. Nevertheless, most donors today would favor laparoscopy, if they could chose again. How laparoscopy affects a reluctant donor to step forward must be determined in a prospective study.

20-year experience with elderly donors in living renal transplantation

PURPOSE

This study evaluates the impact of living renal donors (LD) aged 60 years and older on graft performance and patient survival in an old-for-young constellation.

PATIENTS AND METHODS

We analyzed 144 consecutive LDs between January 1983 and December 2002 (19 patients 60+/125 controls).

RESULTS

Mean donor age in the 60+ group was 63.7 (+/- 2.6) years and 43.7 (+/- 9.0) years for the <60 group. Mean recipient age was 42.4 (+/- 15.2) years versus 32.6 (+/- 15.3) years HLA-A, -B, and DR-mismatches were 3.16 (+/- 1.3) for the 60+ group and 3.13 (+/- 1.7) for the controls (P = NS). Rejection episodes in the first year following LD did not differ (53% versus 33%, P =.25). Mean serum creatinine for 65+ versus <65 after 1, 3, and 12 months was 1.91 +/- 1.2 versus 1.48 +/- 0.85 mg/dL (P =.16), 1.82 +/- 0.89 versus 1.29 +/- 0.35 mg/dL (P <.05) and 1.80 +/- 0.31 versus 1.37 +/- 0.38 mg/dL (P <.05) and mean creatinine clearance at 12 months 62 versus 82 mL/min (P =.06). Censored 1-, 3-, and 5-year graft survival was 100% versus 95% (P = NS), 100% versus 93% (P = NS) and 100% versus 83% (P = NS) with no significant difference in the log-rank test for Kaplan Meier.

CONCLUSION

No impact of donor age was found for graft survival but function of the 65+ kidneys at 3 and 12 months was reduced. Living renal donors 60+ are acceptable for carefully allocated recipients.

Living donor Nephrectomy—No impact of genetic relationship

PURPOSE

A retrospective, single-center analysis was conducted to compare the results of living donor kidney transplantation between living unrelated (LURD) and living related (LRD) donors.

PATIENTS AND METHODS

One hundred forty-seven consecutive living renal transplantations were performed at our institution, starting in 1983. Graft and patient survival were assessed as well as transplant function, including a subgroup analysis for the period of kidney transplantation.

RESULTS

Mean follow up for the LRD group was 88.5 months and for the LURD cohort 34.4 months. One- and 3-year graft survival (censored for death with functioning graft) for LRD versus LURD was 97.5% versus 94.4% (P =.4) and 95.3% versus 88.8% (P =.35). Patient survival at 1 and 3 years was 95.1% versus 94.7% (P =.91) and 87.8% versus 90.0% (P =.79). Of the related recipients, 37% experienced at least one episode of rejection in the first year following renal transplantation, compared to 34% in the LURD group (P =.80). Mean serum creatinine for LRD versus LURD after 1, 3, and 12 months () was 1.52 +/- 0.81 versus 1.59 +/- 1.17 mg/dL (P =.98), 1.41 +/- 0.55 versus 1.30 +/- 0.40 mg/dL (P =.51), and 1.44 +/- 0.39 versus 1.40 +/- 0.40 mg/dL (P =.75). Mean creatinine clearance after 1 year was 82.2 versus 71.7 mL/min (P =.26). Subgroup analysis for the time between 1996 and 2002 revealed no difference between LURD and LRD. Multivariate analysis could exclude an impact of the significantly different recipient age and of first/second warm ischemic time on the endpoints described above.

CONCLUSION

LURD is a good way to meet the growing organ shortage and should be encouraged.

Tumor type M2 pyruvate kinase expression in metastatic renal cell carcinoma

The M2 isoenzyme of pyruvate kinase (M2-PK) is specifically expressed in tumor cells (TuM2-PK) and has been detected in the peripheral blood of patients with renal cell carcinoma (RCC). TuM2-PK is not useful as a biological marker in localized RCC. We analysed TuM2-PK in 68 patients with metastatic RCC after initial surgery and prior to or during chemoimmunotherapy of metastases. In 50 patients, the levels of TuM2-PK were measured during chemoimmunotherapy with interleukin-2, interferon-alpha2a and 5-fluorouracil for up to 8 months and were correlated to response as assessed by radiological imaging techniques. TuM2-PK was quantified with a commercially available enzyme linked immunosorbent assay kit using a cut off of 15 kU/l. In 48 of 68 patients (71%), TuM2-PK was elevated above the cut-off. TuM2-PK was significantly higher in G3 tumors than in G2 tumors. In 34 of 50 patients (68%) undergoing chemoimmunotherapy, a positive correlation between TuM2-PK values and response to treatment was observed. Based on these data, we would not recommend the routine clinical use of TuM2-PK in metastatic RCC at this point.

[Improvement of hemostasis in laparoscopic and open partial nephrectomy with gelatin thrombin matrix (FloSeal)]

Long-term follow-up studies have demonstrated that effective local tumor control and long-term tumor-free progression rates can be achieved by nephron-sparing surgery. However, hemostasis is a major issue and the lack of effective means of hemostasis has limited a wider use of the laparoscopic approach to nephron-sparing surgery. Between January 2001 and August 2002, a total of 36 patients with renal cell carcinomas were treated by partial nephrectomies using a two-component tissue sealant (FloSeal). The median age was 55.2 years (range: 34-71 years). Follow-up time was 1-18 months (median: 5.5 months). The tumor diameter ranged from 2 to 5 cm (median: 2.9 cm). Open retroperitoneal surgery was performed in 17 cases and laparoscopic partial nephrectomy in 19 cases. The two-component tissue sealant (consisting of a gelatin matrix with granular and thrombin components) was applied after resection of the tumor and before perfusion of the kidney. The following parameters were recorded: (1) time until complete hemostasis was achieved, (2) decrease in postoperative hemoglobin level, (3) postoperative bleeding, and (4) presence or absence of a perirenal hematoma 24 h and 10 days postoperatively by ultrasound. After application of the tissue sealant for 1-2 min to the moist resection site, hemostasis was immediate in all cases. During the laparoscopic partial nephrectomies, a laparoscopic applicator was used that avoided wasting the tissue sealant within the dead space of the instrument. When reperfusion of the kidney was established, hemostasis was maintained. The decrease in postoperative hemoglobin level ranged from 0.3 to 1.2 points (median: 0.8 points). None of the patients required blood transfusions. There were no cases of postoperative bleeding. An ultrasound examination 24 h and 10 days postoperatively demonstrated the absence of a significant perirenal hematoma. The two-component tissue sealant FloSeal provided immediate and durable hemostasis in open and laparoscopic partial nephrectomies. The tissue sealant may provide a tool to expand the possibilities of laparoscopic nephron-sparing surgery.

[Laparoscopic dismembered pyeloplasty with Anderson-Hynes technique]

Because of the minimal invasiveness of the laparoscopic approach, we introduced the laparoscopic dismembered pyeloplasty in our treatment modalities for patients with primary UPJ obstruction. We report on our technique and the results after a median follow-up of more than 2 years. Between August 1997 and September 2002, 52 patients underwent a laparoscopic dismembered pyeloplasty at our institution. All patients had a symptomatic primary PJ obstruction. We prefer the transperitoneal route with laterocolic exposure of the kidney. After preparation and exposure of the ureter and the renal pelvis, we performed in each case the dismembered Anderson-Hynes pyeloplasty with resection of the pelvis and reanastomosis between the ureter and renal pelvis. Intracorporeal suturing and knotting techniques were used exclusively. All procedures could be performed successfully. In no case was conversion to open surgery necessary. The mean operative time was 180 min. Crossing vessels were present in 57% of patients. The mean postoperative hospital stay was 4 days. The first patient had an anastomosis insufficiency, which required laparoscopic repair. The same patient failed in the follow-up. He developed a late recurrence of the stenosis and needed an open repair. In all other patients the obstruction was resolved or significantly improved. The long-term success rate is 98% with a follow-up of 25 months. Our results with laparoscopic dismembered pyeloplasties compare favorably with those achieved by open pyeloplasties with less perioperative morbidity and discomfort. We do believe that laparoscopic dismembered pyeloplasty will be the method of choice in the treatment of UPJ obstruction.

[Renal carcinoma with invasion of the suprahepatic vena cava (Staehler stage III and IV): surgical treatment and results]

The operative treatment of patients with renal cell carcinoma (RCC) and suprahepatic infradiaphragmatic or supradiaphragmatic vena cava invasion (Staehler stage III and IV) is still an interdisciplinary challenge. The potential high complication rate and the enormous operative-technical efforts have to be brought into line with the individual benefit for the patient. In this study, we have retrospectively analyzed the operative results of 24 patients. We have further compared the patients during follow-up and immunotherapy due to metastasis with a control group of 75 patients without vena cava invasion. Perioperative mortality in the 24 patients was 4%. Four patients had metastasis at presentation and 14 further patients developed metastatic disease during median follow-up of 23.5 months. Median survival was 45 months with a 1-, 3-, and 5-year survival rate of 92, 57, and 33%, respectively. In a multivariate analysis, only the presence of metastasis (p=0.002) and marginal immunotherapy (p=0.1), but not vena cava invasion (p=0.259) or a positive lymph node status (p=0.624) were significant predictors of a poor survival. For patients with RCC and suprahepatic infradiaphragmatic or supradiaphragmatic vena cava invasion (Staehler stage III and IV), the combination of an aggressive surgical treatment combined with subsequent immunotherapy in the presence of metastatic disease offers a realistic therapeutic option with reasonable survival rates.

[Laparoscopic transperitoneal donor nephrectomy. Technique and results]

Living donor kidney transplantation is one possibility to meet the growing demand for organs in patients with chronic renal failure. In 1995 the first laparoscopic living donor nephrectomy (LDN) was performed in the United States. More than 100 transplant centers worldwide perform LDN. The expectations of a larger number of willing organ donors were fulfilled due to the less traumatic operation. Meanwhile, several techniques exist to retrieve a kidney laparoscopically, including the trans- or retroperitoneal, strictly laparoscopic, or hand-assisted approach. From February 1999 to September 2002, 63 strictly laparoscopic, transperitoneal LDNs were performed at the Department of Urology of the Charité University Hospital, Berlin. Warm ischemic time was 148 s (105-360) and operating time was 203 min (110-305). Intraoperative complications were due to insufficient closure of the vessels in four patients. Mean postoperative hospital stay was 5.7 days (3-9). One year after LDN, renal function as well as creatinine levels of the recipient showed no difference compared to the organs harvested via the approach at our department prior to implementation of LDN. Strictly laparoscopic transperitoneal donor nephrectomy is a safe method for kidney retrieval and ensures excellent graft function.

[Laparoscopic living donor nephrectomy of kidneys with multiple renal vessels]

Due to the increasing waiting time for transplantation of a cadaveric kidney, living donor kidney transplantation is an increasingly oncoming issue. Laparoscopic donor nephrectomies (LDN) have been performed since 1995 and presently more than 100 transplant centers offer this minimally invasive surgical approach. The advantages for the donor of less pain, shorter hospital stay, earlier return to work, better cosmetic results in combination with an organ function equal to open donor nephrectomy are the reasons for an enormous increase in LDN. Since up to 30% of the donor kidneys have multiple vessels for blood supply, an increase of these organs for LDN can be expected. We performed a retrospective study of LDN at our center and compared donors with multiple vs single vessel supply. From February 1999 to September 2002, 63 LDN were performed at the department of Urology, Charité University Hospital, Berlin. A comparison between 18 donor kidneys with multiple vessel supply and 45 donor organs with single vessels showed no difference for the time of laparoscopic explantation (207 vs 201 min, p=0.4) or the warm (166 vs 148 s, p=0.2) and cold ischemic times (117 vs 103 min, p=0.66). As could be expected, the mixed ischemic time, i.e., the time for anastomosis of the kidney with the recipient's vessels, showed a significant difference (53 vs 46 min, p=0.02). Intra- and postoperative complication rates for donors and recipients were not different in both groups. Laparoscopic donor nephrectomy for kidneys with multiple vessels is feasible and safe for donor and recipient.

[Laparoscopic radical nephrectomy: indications, techniques, and oncological outcome]

Renal cell carcinoma is likely to become one of the most important indications for laparoscopic surgery worldwide. The laparoscopic technique combines the benefits of the minimally invasive approach with established surgical principles. In our institution the laparoscopic transperitoneal approach with intact specimen extraction has become the standard technique for radical nephrectomies. We report the indications, techniques, and oncological outcome in a single center experience in 100 cases. The mean tumor size was 5.9 cm (range: 2-11 cm), the blood loss was 220 ml, and the mean surgical time was 211 min, including the learning curves of five surgeons. Histological findings were pT1 in 66 (66%), pT2 in 11 (11%), and pT3 in 19 (19%) patients with an increasing tumor size according to the experience of the surgeons. In four cases (4%) histology did not prove malignant disease. Positive lymph nodes were detected in three cases (3%) and surgical margins were negative for tumor in all patients. To date 61 patients were available for follow-up; patients with primary metastatic disease were excluded from this analysis. Follow-up was between 1 and 30 months with an average of 12.9 months. Progressive disease occurred in two cases in patients with pT3G3 tumors. No cases of local recurrence or port metastasis occurred during observation. Laparoscopic radical nephrectomy is a routine, effective treatment for patients with renal cell carcinoma. Our follow-up data up to 30 months confirm the effectiveness of laparoscopic radical nephrectomy in terms of surgical principles and oncological outcome.

Short communication serum copper, zinc, and calcium concentrations in lice-infested sheep

The purpose of this study was to investigate changes in serum concentration of copper, zinc, and calcium in sheep naturally infested with lice (Bovicola caprae, Linognathus africanus, Linognatus ovillus, and Linognattus pedalis). Twenty sheep naturally infested with lice and 20 healthy sheep were used as subjects. Blood samples were collected from the sheep before and 8 and 15 d after treatment with Avermectin, a veterinary antiparasitic drug. The samples were analyzed for their serum copper, zinc, and calcium concentrations by atomic absorption spectrometry. The concentrations of these elements in the infested animals were lower than in the healthy controls, mainly because the general condition of the affected sheep was poor. When the infested animals were treated with an ectoparasitic drug, the serum levels of the studied elements rose to normal ranges while the health of the animals improved.

[Laparoscopic radical cystectomy with intracorporeal creation of a continent urinary diversion. Future or present?]

Once laparoscopic radical prostatectomy has been mastered, the step to performing a radical cystectomy is not that far. The challenge is to create the urinary diversion by laparoscopy. In this report we describe our experience with 11 laparoscopic radical cystectomies and intracorporeal construction of a continent urinary diversion (Mainz pouch II) as a treatment option in patients with muscle-invading bladder cancer. All 11 procedures could be performed successfully. A conversion to open surgery was not required in any case. The mean surgery time was 6.7 h. Except for two pouch fistulas we did not observe any intra- or postoperative complications. The functional as well as the oncological results are convincing. Less morbidity and faster recovery are the main advantages of this minimally invasive procedure. In addition, the low levels of blood loss, fluid shifts, and electrolyte loss considerably reduce cardiovascular stress. Radical cystectomy and construction of a continent urinary diversion represent the limit of technically feasible laparoscopy and should be done exclusively in specialized centers.

[Radical prostatectomy in clinically localized prostate carcinoma. Pro laparoscopic approach]

Systematic development of laparoscopy during the last decade has led to establishing laparoscopic radical prostatectomy (LRP) as a surgical procedure. On the basis of extensive experience at our center, the advantages of the minimally invasive method are described as well as the problems still in existence. Reduced trauma caused by laparoscopic access in combination with clearly reduced blood loss has resulted in less morbidity after laparoscopic procedures. This is reflected in a shorter postoperative stay in hospital and faster convalescence. LRP as an ambitious and complex procedure has an average complication rate of 12%, which shows that the method has surpassed the stage of experimental surgery. By direct comparison, the costs of LRP are higher than for the open surgical procedure, but on the whole this is economically balanced by the lower morbidity, shorter hospital stay, and faster convalescence. The progress in technology to be expected in the field of laparoscopy will further increase quality, precision, and safety of LRP and thus contribute to the establishment of laparoscopic radical prostatectomy as a surgical method of choice.

Laparoscopic radical prostatectomy. Technical aspects and experience with 125 cases

PURPOSE

The laparoscopic access for radical prostatectomy offers an alternative to the open surgical procedure with less morbidity. We report on our experience with 125 laparoscopic prostatectomies, especially with respect to making the laparoscopic approach a routine procedure and with a view to the oncological and functional results.

MATERIAL AND METHODS

From June 1999 to September 2000, we performed 125 laparoscopic prostatectomies. These included only patients with cancer stages T1 or T2. The mean PSA concentration was 10.5 ng/ml. Forty-four percent of the patients had undergone previous abdominal and 19% previous transurethral surgery. For our laparoscopic prostatectomies we used the descending technique. Free-hand laparoscopic suturing and in situ knot-tying technique were used for the urethrovesical anastomosis. The mobilized specimens were removed in an endobag via a muscle splitting incision.

RESULTS

All 125 procedures could be completed successfully. No case required conversion to open surgery. The average operating time was 255 min, the last 40 procedures taking 200 min only. Mean blood loss was 185 ml. Two patients (2%) required postoperative blood transfusion. After an initial learning curve, catheter remained in place for an average of 5.5 days, and the average postoperative stay in hospital was 8 days. Intraoperative complications were seen in 5 patients (4%). In 13 patients (10.4%) postoperative complications were observed. 86% of the patients are continent 6 months postoperatively. Preservation of the neurovascular bundle and sexual potency is possible.

CONCLUSION

Laparoscopic radical prostatectomy is an ambitious procedure with a steep learning curve, especially for the laparoscopic dissecting and suturing technique. The excellent sight for dissection results in a reduced blood loss and faster convalescence with an overall lower morbidity. Also with regard to oncological and functional (continence) results the minimally invasive access is at least equivalent to the open procedure. In our opinion, laparoscopic prostatectomy will be the future method of choice for radical prostatectomy.

Laparoscopic radical cystectomy with continent urinary diversion (rectal sigmoid pouch) performed completely intracorporeally: the initial 5 cases

PURPOSE

We present our experience with the first 5 patients who underwent radical cystectomy with bilateral pelvic lymphadenectomy and continent urinary diversion (rectal sigmoid pouch) performed with an intracorporeal laparoscopic technique at our center.

MATERIALS AND METHODS

There were 3 males and 2 females 59 to 65 years old with organ confined, muscle invasive transitional cell carcinoma of the bladder who underwent surgery. The procedure included pelvic lymph node dissection, radical cystectomy with prostate or uterus and tubal structures, creation of the rectal sigmoid pouch and bilateral stented antireflux implantation of the ureters into the pouch. Freehand laparoscopic suturing and in situ knot tying techniques were used exclusively. The mobilized specimens were removed in an endoscopy bag via the rectum or vagina. Laparotomy was not required.

RESULTS

Operating time was 6.9 to 7.9 hours (median 7.4) and blood loss was 190 to 300 ml. (median 245). None of the 5 patients none needed blood transfusion. Oral intake was started on hospital day 3, ureteral stents were removed on day 8 and the pouch catheter was removed on day 9. The hospital stay was 10 days for all cases. Histopathological examination of the specimens revealed stage pT1 G3 urothelial carcinoma in case 1, pT2b G2 in cases 2 and 3, pT3a G2 in case 4 and pT3aG3 in case 5. The lymph nodes and resection margins were tumor-free. No intraoperative or postoperative complications were observed.

CONCLUSIONS

To our knowledge, this is the first series of laparoscopic radical cystectomy with intracorporeal continent urinary diversion (rectal sigmoid pouch), and our results are promising. With more experience and improvement of the surgical technique, laparoscopic radical cystectomy with continent urinary diversion may become an alternative surgical method for treating select patients with localized muscle invasive bladder cancer.

[Brachytherapy of local prostatic carcinoma]

Brachytherapy of prostate cancer has become attractive in recent years in Germany. There are several radioactive sources available, which are physically different. Some of them are used as permanent or temporary implants. The permanent sources most frequently used are iodine 125, palladium 103, and gold 198. Iridium is a temporary implant. The techniques used in Germany are low-dose rate (LDR) and high-dose rate brachytherapy, which differ in dose distribution and patient population. The success of prostate cancer brachytherapy depends on patient selection and choosing the right source for the technique used. Best suited for LDR monotherapy is the low-risk patient with a prostate-specific antigen (PSA) level below 10 ng/ml, maximal tumor stage T2b, and a Gleason score of less than 7.

[Thermoradiotherapy with interstitial thermoseeds in treatment of local prostatic carcinoma. Initial results of a phase II study]

Several experimental data are available regarding the efficacy of the combination of interstitial hyperthermia and conformal radiation therapy. We planned a phase II trial as a member of the special hyperthermia research group of the Deutsche Forschungsgemeinschaft (German Research Society) to determine the efficacy of thermoradiotherapy using interstitial cobalt-palladium thermoseeds in the treatment of patients with localized prostate cancer. Forty-one patients with localized prostate cancer were enrolled in the study between July 1997 and April 2000. The interstitial hyperthermia induced in a magnetic field was applied in six sessions once a week. Conformal three-dimensional radiation therapy was given simultaneously in daily fractions of 1.8 Gy with a total dose of 68.4 Gy. We measured intraprostatic temperatures between 42 degrees and 46 degrees C. No major side effects were observed during the hyperthermia session. The median level of prostate-specific antigen (PSA) decreased from 11.25 ng/ml to 0.88 ng/ml 3 months after treatment and to 0.38 ng/ml 12 months after treatment with a median follow-up of 10 months. The mean prostate volume decreased from 32.6 ml to 26 ml after 3 months of treatment and to 18.5 ml after 12 months. Interstitial hyperthermia is a feasible, well-tolerated procedure in prostate cancer therapy. A significant PSA decrease was observed. Longer follow-up is necessary to determine the efficacy.

Complete laparoscopic approach for radical cystectomy and continent urinary diversion (sigma rectum pouch)

Technical and manual progress made in recent years now enables large uro-oncological procedures to be performed by means of laparoscopy. We report the first successful radical laparoscopic cystectomy and laparoscopic construction of a continent urinary diversion. Laparotomy can be avoided completely. The advantages are clear reduction of blood loss and postoperative morbidity with faster convalescence.

[MRI of the prostate after combined radiotherapy (afterloading and percutaneous): histopathologic correlation]

AIM

To identify the MRI changes of the prostate after combined (high-dose rate interstitial with external beam) radiotherapy for, localized prostate cancer and to correlate the findings with histology in order to determine the value of MR imaging in the follow-up of these patients.

MATERIAL AND METHODS

Twenty-three patients underwent MR imaging at 1.5 T between 6 and 24 months after completion of combined radiotherapy. The prostate was imaged with axial and coronal T2-weighted sequences and axial T1-weighted sequences before and after intravenous administration of Gd-DTPA. Quadrant or sextant biopsy was performed in all cases and three patients with proven persistence of the tumor underwent salvage prostatectomy. The MRI findings were compared with the biopsy results or the large-area sections.

RESULTS

On T2-weighted images the fibrotically changed peripheral zone was hypointense while persistent tumor tissue showed hyperintensity. Solid tumors were depicted when they had a diameter of 1 cm or more. Persistent tumors of the diffuse multifocal type escaped detection. Contrast-enhanced T1-weighted imaging yielded no additional information. The accuracy in detecting persistent tumor was 74%.

CONCLUSIONS

Histopathologic changes seen after combined radiotherapy correlate with the findings on T2-weighted MR images. MR imaging cannot replace follow-up by routine biopsy. Its only role is assessing local operability in cases found to have increasing PSA levels during follow-up. Further studies are needed to determine the role of MR imaging in this patient population.

[Value of radiotherapy in urology]

Radiotherapy of patients with prostate cancer offers an alternative to radical prostatectomy in early stages (T1-T2). In locally advanced prostate cancer a high dose or combined radiotherapy is more effective than radical surgery with concurrent lower morbidity and mortality. Recent developments in linear accelerator technique, the progress in dose calculation and planning techniques provide the means to apply higher doses to a given tumor volume while effectively protecting the surrounding normal tissue at the same time. These improvements may possibly reduce the rate of therapy related side effects or complications significantly. The combination of external beam radiotherapy and interstitial brachytherapy as well as the combination of hormone therapy and external beam radiotherapy are most likely more effective than percutaneous irradiation alone. In special cases with a very low risk of recurrent tumor an interstitial permanent brachytherapy alone is indicated. Future developments (i.e. intensity modulated radiotherapy-IMRT, combined thermo-radiotherapy, proton- or neutrontherapy) may further increase the rate of curative treatments in patients with prostate cancer.

High-dose rate interstitial with external beam irradiation for localized prostate cancer--results of a prospective trial

PURPOSE

A prospective phase II trial was carried out to test the feasibility and effectiveness of a combined interstitial with external beam radiotherapy approach for localized prostate cancer.

MATERIALS AND METHODS

Between October 1992 and December 1994, 82 evaluable patients were treated. T2 and T3 tumours, according to the AJCC classification system of 1992, were found in 21 and 61 cases, respectively. The median follow-up was 24 months; three patients were lost during follow-up. All of the patients were pathologically proven to be node-negative by laparoscopic node dissection of the fossa obturatoria region. A dose of 9 Gy a week was prescribed during the first and second weeks of treatment (10 Gy each week from October 1992 to December 1993) interstitially with high-dose rate Iridium-192 brachytherapy to the prostate and tumour extension beyond the capsule. External beam four-field box irradiation was then given to the prostate to a dose of 45 Gy/25 fractions (40 Gy/20 fractions from October 1992 to December 1993).

RESULTS

Before starting treatment, a PSA value of > or =10 ng/ml was found in 64.6% (53/82) of patients with a median PSA of 14.0 ng/ml. The median PSA 3, 12 and 24 months after completion of therapy was 1.20, 0.78 and 0.70 ng/ml, respectively. The PSA value was < 1.0 ng/ ml in 52.9% of patients at 2 years. Negative punch biopsies 12 and 24 months after therapy were observed in 69.8% (44/63) and 73. 1% (38/ 52) of patients, respectively. A positive biopsy combined with a PSA value of > 1.0 ng/ml was considered as local failure. The local tumour control rate was 79.5% at 2 years. Acute side-effects were not increased relative to external beam irradiation alone. Severe side-effects were observed in three patients (two of the three patients had additional risk factors (colitis ulcerosa and diabetes mellitus)); they developed rectourethral fistulae requiring colostomy after biopsies from the anterior rectal wall.

CONCLUSION

The described method is feasible and well tolerable. The three complications observed were not caused by irradiation alone. Biopsies from the anterior rectal wall after definitive high-dose radiotherapy for prostate cancer have to be seen as obsolete. The rate of negative prostate biopsies of 73.1% after 24 months represents an encouraging result.

High-dose rate iridium192 afterloading therapy in combination with external beam irradiation for localized prostate cancer

Development of afterloading techniques in combination with external radiotherapy allows for curative therapy modality for stage C prostate cancer. Between 10/92 and 12/95 128 patients were treated. Stage B and C tumors were found in 36 and 89 cases, respectively. All patients were pathologically proven to be node-negative by laparoscopic node dissection of the fossa obturatoria region. 9 Gy a week was applied during the first and second weeks of treatment (10/92-12/93: 10 Gy each week) interstitially with high-dose rate iridium192 brachytherapy to the prostate. After this, a four-field box of external beam radiation therapy was given to the prostate to a dose of 45 Gy/25 fractions (10/92-12/93: 40 Gy/20 fractions). Before starting treatment median PSA was 13.8 ng/ml. The median PSA 3, 12, and 24 months after completion of therapy was 1.2, 0.78, and 0.75 ng/ml, respectively. Negative biopsies 12 and 24 months after therapy were observed in 56% (49/87) and 72% (31/43), respectively.

Laparoscopic ureterolithotomy

We report about the successful laparoscopic removal of ureteral stones. Since July 1993, 21 patients with large ureteral calculi have undergone laparoscopic ureterolithotomy. In 19 of 21 patients, laparoscopic ureterolithotomy was successful. The mean operating time was 90 minutes. The postoperative inhospital stay was 1 to 4 days. Laparoscopic ureterolithotomy offers an alternative to open surgery in patients with large ureteral stones or when less invasive measures fail.

Status of the tick-borne diseases in sheep and goats in Turkey

A serological survey using Indirect Fluorescent Antibody Test (IFAT) for Babesia ovis infection of sheep has been carried out in different geographical regions of Turkey. The results indicated that 71.6% of 141 sheep in Black Sea region, 70.9% of 93 sheep in central Anatolia, 80.2% of 96 sheep in Aegean region and 55.7% of 122 sheep in eastern Anatolia were seropositive. This means that B. ovis infection is endemic throughout Turkey. In addition, occurrence of B. ovis, B. motasi, Theileria hirci, T. recondita and Anaplasma ovis infections in sheep and goats has been reported previously in Turkey as well. However further studies are needed to obtain more information about the agents to keep the infection under control.