Publications by authors named "Johannes Mischinger"

35 Publications

Utility of pT3 substaging in lymph node-negative urothelial carcinoma of the bladder: do pathologic parameters add to prognostic sub-stratification?

World J Urol 2021 Apr 21. Epub 2021 Apr 21.

Department of Urology, University Hospital, Tübingen, Germany.

Purpose: The value of bladder cancer (BC) substaging into macroscopic (pT3b) and microscopic (pT3a) perivesical fat extension in lymph node (Ln)-negative patients is controversially discussed and limited evidence for prognostic relevance of additional histopathological factors in pT3 BC exists. We evaluated the prognostic value of pT3 substaging and established pathological and clinical parameters with focus on tumor invasive front (TIF) and tumor size.

Methods: Specimens of 52 patients treated with radical cystectomy (RC) for pT3 a/b muscle-invasive BC were reviewed and re-evaluated by a pathologist specialized in uropathology. Clinical variables and standard histopathologic characteristics were assessed including TIF and tumor size. Their value as prognosticators for overall survival (OS) and recurrence-free survival (RFS) was evaluated.

Results: Mean age of patients was 67.55 years. Tumors were staged pT3a in 28 patients (53.8%) and pT3b in 24 (46.8%). Median OS was 34.51 months. Median tumor size was 3.2 cm, median TIF was 11.0 mm. Differences in OS between pT3a and pT3b were not significant (p = 0.45). Carcinoma in situ (CIS) and lymphovascular invasion (LVI) were significantly associated with pT3b tumors. Univariate analysis could not identify pathological prognosticators like TIF or tumor size for OS and RFS (p for all > 0.05).

Conclusion: No significant differences in OS or RFS were observed comparing Ln-negative pT3 BC following radical cystectomy. Additional pathologic variables like TIF could not be identified as prognosticator. Relevance of pT3 BC substaging needs reevaluation in larger prospective cohorts.
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http://dx.doi.org/10.1007/s00345-021-03697-3DOI Listing
April 2021

A Modified Neobladder Technique: The "I-Pouch" - Illustration of Surgical Approach and Tricks.

Urology 2021 Jan 26;147:318. Epub 2020 Oct 26.

Department of Urology, Eberhard-Karls-University Tübingen, Tübingen, Germany. Electronic address:

Objective: Various techniques for orthotopic neobladder (ONB) are currently used and have shown satisfactory oncological and functional outcomes. Among the relevant oncological and functional aspects for long-term follow up is the easy accessibility of the upper urinary tract in urinary diversion for endoscopic monitoring. In addition, variety exists in the amount of ileum needed to create a urinary reservoir. Depending on the ONB technique, up to 60 cm of ileum are required, and bowel dysfunction may be a consequence especially when the ileocecal valve is used for the urinary diversion. We previously reported the technique, functional and oncologic results of the I-pouch, a modified ONB made of 40 cm of ileum, combining an antirefluxive ureter implantation technique with easy access to the uretero-intestinal anastomosis. The present video is intended to illustrate key surgical steps and pitfalls during the procedure.

Methods: The technique, surgical tips, and functional results in a as compared to a institutional control group receiving conventional Studer -Pouch-procedure are outlined.

Results: In a follow up series of 33 I-pouch and 23 S-pouch patients, there were no differences according to ONB type for 30-day major- (P = .33) and minor (P = 0.96) complication rates although 90-day major (P = 0.08) and minor (P = 0.08) complication rates tended to be associated with less complications in I-pouch patients.

Conclusion: The I-pouch can be used for neobladder substitution providing easy access to the upper urinary tract, reduced demand of ileum length along with a complication profile not distinct from Studer neobladder formation.
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http://dx.doi.org/10.1016/j.urology.2020.10.017DOI Listing
January 2021

Prognostic value of B7-H1, B7-H3 and the stage, size, grade and necrosis (SSIGN) score in metastatic clear cell renal cell carcinoma.

Cent European J Urol 2019 14;72(1):23-31. Epub 2019 Mar 14.

Department of Urology, Medical University of Graz, Graz, Austria.

Introduction: We compared the potential prognostic impact of B7-H1 and B7-H3 glycoprotein expressions with the Mayo Clinic Stage, Size, Grade, and Necrosis (SSIGN) score in metastatic clear cell renal cell carcinoma (mccRCC) during a long term follow-up.

Material And Methods: We investigated 44 mccRCC patients, who underwent radical nephrectomy between 1995 and 2006 at a single tertiary academic center and received interferon therapy (IFNT) for at least three months. The SSIGN score was applied as a validated prediction outcome model. Representative tumor sections were immunostained with anti-B7-H3 and anti-B7-H1 antibodies. Hereafter, positive antigen-antibody reactions were measured using the Positive-Pixel-Count Algorithm of the Aperio-Technology Image Scope software.

Results: In total, 48% of patients were treated with cytoreductive nephrectomy and postoperative IFNT due to synchronous mccRCC, whereas 52% received IFNT after developing metachronous mccRCC. The SSIGN score was independently associated with a higher mortality risk. Patients with a SSIGN score ≤9 showed an extended 'nephrectomy to start of INFT'-interval (p = 0.02), less synchronous clinical metastases (p = 0.0002), as well as an increased median overall - (OS) or cancer-specific survival (CSS) (p = 0.01), respectively. Furthermore, B7-H3 expression levels of ≤16% were associated with an improved OS or CSS and correlated with a more frequent pathologic grade 1-2, as well as a longer 'nephrectomy to start of IFNT'-interval, respectively. B7-H1 expression patterns did not correlate with survival.

Conclusions: The SSIGN score demonstrated the best prognostic performance. In contrast, B7-H3 expression patterns showed a low association with histopathological parameters, but predicted the cut-off-dependent impaired survival and in the future may define a cut-off to indicate checkpoint-inhibitor treatment.
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http://dx.doi.org/10.5173/ceju.2018.1858DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469004PMC
March 2019

Targeted vs systematic robot-assisted transperineal magnetic resonance imaging-transrectal ultrasonography fusion prostate biopsy.

BJU Int 2018 05 15;121(5):791-798. Epub 2018 Jan 15.

Department of Urology, Eberhard Karls University, Tübingen, Germany.

Objective: To evaluate the performance of transperineal robot-assisted (RA) targeted (TB) and systematic (SB) prostate biopsy in primary and repeat biopsy settings.

Patients And Methods: Patients underwent RA biopsy between 2014 and 2016. Before RA-TB, multiparametric magnetic resonance imaging (mpMRI) was performed. Prostate lesions were scored (Prostate Imaging, Reporting and Data System, version 2) and used for RA-TB planning. In addition, RA-SB was performed. Available, whole-gland pathology was analysed.

Results: In all, 130 patients were biopsy naive and 72 had had a previous negative transrectal ultrasonography-guided biopsy. In total, 202 patients had suspicious mpMRI lesions. Clinically significant prostate cancer was found in 85% of all prostate cancer cases (n = 123). Total and clinically significant prostate cancer detection rates for RA-TB vs RA-SB were not significantly different at 77% vs 84% and 80% vs 82%, respectively. RA-TB demonstrated a better sampling performance compared to RA-SB (26.4% vs 13.9%; P < 0.001).

Conclusion: Transperineal RA-TB and -SB showed similar clinically significant prostate cancer detection rates in primary and repeat biopsy settings. However, RA-TB offered a 50% reduction in biopsy cores. Omitting RA-SB is associated with a significant risk of missing clinically significant prostate cancer.
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http://dx.doi.org/10.1111/bju.14089DOI Listing
May 2018

Perioperative morbidity, bowel function and oncologic outcome after radical cystectomy and ileal orthotopic neobladder reconstruction: Studer-pouch versus I-pouch.

Eur J Surg Oncol 2018 Jan 20;44(1):178-184. Epub 2017 Oct 20.

Department of Urology, Eberhard Karls University Tübingen, 72076, Tübingen, Germany. Electronic address:

Objective: To investigate whether the length of ileum used for ileal orthotopic neobladder (ONB) reconstruction (60 cm vs. 40 cm) after radical cystectomy (RC) for bladder cancer (BC) impacts on bowel function, postoperative complications or survival outcome.

Material And Methods: In this retrospective study, we included 56 patients who received an ONB (Studer (S)-Pouch: 23 patients; I-Pouch: 33 patients) after RC for BC between 2003 and 2011. Preoperative comorbidities were assessed by the Charlson Comorbidity Index (CCI) and surgical complications as graded by the Clavien-Dindo classification. Changes of perioperative bowel habits were retrospectively evaluated by the validated Gastrointestinal Quality of Life Index (GIQLI). Kaplan-Meier analyses calculated survival outcomes between both ONB types.

Results: Preoperative CCI was comparable between S- and I-pouch patients. No significant differences were observed for 30-day major- (p = 0.33) and minor (p = 0.96) complication rates between both neobladder types. S-Pouch patients reported higher preoperative stool frequencies (S-pouch: mean 2.7; I-pouch: mean 3.4; p = 0.049) and tended to suffer from urgency (S: mean 2.9; I: mean 3.4; p = 0.059). No significant differences in postoperative bowel disorders were found between both neobladder types (S-Pouch: 15.9, IQR; I-Pouch: 16.6 IQR; p = 0.84). Furthermore, we observed no overall-, cancer specific- or recurrence free survival advantage for either of both ONB variants (p = 0.81; 0.65 and 0.78), respectively.

Conclusion: Comorbidities, perioperative complication rates and bowel habits were similar between both ONB substitutes and did not influence survival outcomes. These stratified data suggest that the length of ileum used for ONB reconstruction (60- vs. 40 cm) does not impact per se on postoperative bowel function.
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http://dx.doi.org/10.1016/j.ejso.2017.10.208DOI Listing
January 2018

The prognostic effect of salvage surgery and radiotherapy in patients with recurrent primary urethral carcinoma.

Urol Oncol 2018 01 18;36(1):10.e7-10.e14. Epub 2017 Oct 18.

Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Background: To evaluate the impact of salvage therapy (ST) on overall survival (OS) in recurrent primary urethral cancer (PUC).

Patients: A series of 139 patients (96 men, 43 women; median age = 66, interquartile range: 57-77) were diagnosed with PUC at 10 referral centers between 1993 and 2012. The modality of ST of recurrence (salvage surgery vs. radiotherapy) was recorded. Kaplan-Meier analysis with log-rank was used to estimate the impact of ST on OS (median follow-up = 21, interquartile range: 5-48).

Results: The 3-year OS for patients free of any recurrence (I), with solitary or concomitant urethral recurrence (II), and nonurethral recurrence (III) was 86.5%, 74.5%, and 48.2%, respectively (P = 0.002 for I vs. III and II vs. III; P = 0.55 for I vs. II). In the 80 patients with recurrences, the modality of primary treatment of recurrence was salvage surgery in 30 (37.5%), salvage radiotherapy (RT) in 8 (10.0%), and salvage surgery plus RT in 5 (6.3%) whereas 37 patients did not receive ST for recurrence (46.3%). In patients with recurrences, those who underwent salvage surgery or RT-based ST had similar 3-year OS (84.9%, 71.6%) compared to patients without recurrence (86.7%, P = 0.65), and exhibited superior 3-year OS compared to patients who did not undergo ST (38.0%, P<0.001 compared to surgery, P = 0.045 to RT-based ST, P = 0.29 for surgery vs. RT-based ST).

Conclusions: In this study, patients who underwent ST for recurrent PUC demonstrated improved OS compared to those who did not receive ST and exhibited similar survival to those who never developed recurrence after primary treatment.
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http://dx.doi.org/10.1016/j.urolonc.2017.09.012DOI Listing
January 2018

The thermoexpandable nitinol stent: a long-term alternative in patients without nephropathy or malignancy.

Scand J Urol 2017 Oct 23;51(5):388-391. Epub 2017 Jun 23.

a Department of Urology , Eberhard-Karls-University , Tuebingen , Germany.

Objective: The aim of this study was to investigate the long-term outcome of a thermoexpandable nickel-titanium nitinol ureteral stent (Memokath 051™) and to identify individual risk factors for failure.

Materials And Methods: This retrospective single-centre study included 125 patients who underwent implantation of the self-expandable Memokath 051 stent. Complications, indwelling time and reason for explantation were recorded. Analyses were stratified by gender, age, body mass index, American Society of Anesthesiologists score, estimated glomerular filtration rate (eGFR), side, localization and cause of the stricture.

Results: In total, 91 out of 125 patients (73%) were available for analysis. Median indwelling time was 355 days (range 7-2125 days). Most stents were removed because of dislocation (42%) or occlusion (40%). Stent removal was rarely performed because of infection (3%). Patients with sufficient renal function (eGFR ≥60 ml/min/1.73 m²) showed increased indwelling times compared with those with nephropathy (386 vs 317 days; p < 0.01). Patients with active malignant disease showed reduced patency time compared with strictures of benign origin (455 vs 190 days; p < 0.01).

Conclusions: This thermoexpandable nitinol stent offers safe mid-term treatment of ureteric strictures, especially in patients without active malignancy and with good renal function.
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http://dx.doi.org/10.1080/21681805.2017.1331262DOI Listing
October 2017

Erratum: Large-field-of-view optical elastography using digital image correlation for biological soft tissue investigation (erratum).

J Med Imaging (Bellingham) 2017 Apr 1;4(2):029801. Epub 2017 Jun 1.

Universität Stuttgart, Institut für Technische Optik, Stuttgart, Germany.

[This corrects the article DOI: 10.1117/1.JMI.4.1.014505.].
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http://dx.doi.org/10.1117/1.JMI.4.2.029801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5452429PMC
April 2017

Large-field-of-view optical elastography using digital image correlation for biological soft tissue investigation.

J Med Imaging (Bellingham) 2017 Jan 16;4(1):014505. Epub 2017 Mar 16.

Universität Stuttgart , Institut für Technische Optik, Stuttgart, Germany.

In minimally invasive surgery the haptic feedback, which represents an important tool for the localization of abnormalities, is no longer available. Elastography is an imaging technique that results in quantitative elastic parameters. It can hence be used to replace the lost sense of touch, as to enable tissue localization and discrimination. Digital image correlation is the chosen elastographic imaging technique. The implementation discussed here is clinically sound, based on a spectrally engineered illumination source that enables imaging of biological surface markers (blood vessels) with high contrast. Mechanical loading and deformation of the sample is performed using a rolling indenter, which enables the investigation of large organs (size of kidney) with reduced measurement time compared to a scanning approach. Furthermore, the rolling indentation results in strain contrast improvement and an increase in detection accuracy. The successful application of digital image correlation is first demonstrated on a silicone phantom and later on biological samples. Elasticity parameters and their corresponding four-dimensional distribution are generated via solving the inverse problem (only two-dimensional displacement field and strain map experimentally available) using a well-matched hyperelastic finite element model.
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http://dx.doi.org/10.1117/1.JMI.4.1.014505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5352912PMC
January 2017

Comparison of different concepts for interpretation of chromosomal aberrations in urothelial cells detected by fluorescence in situ hybridization.

J Cancer Res Clin Oncol 2017 Apr 2;143(4):677-685. Epub 2016 Dec 2.

Department of Urology, University Hospital Tuebingen, Eberhard-Karls University, Hoppe-Seyler Street 3, 72076, Tübingen, Germany.

Purpose: Urine fluorescence in situ hybridization (FISH) has become a broadly used marker for noninvasive detection of bladder cancer (BC). However, it has been discussed whether the interpretation algorithm proposed by the manufacturer could be improved. Aim of the present study was to compare alternative evaluation strategies of FISH for detection of BC.

Methods: We included 1048 patients suspicious for BC, who underwent urine FISH examination before cystoscopy (diagnostic cohort). Herefrom, we selected 122 patients (prognostic cohort) with a history of non-muscle-invasive BC who were cystoscopically tumor free and received FISH analysis ahead of a follow-up period of 24 months. FISH results were interpreted by the algorithms of UroVysion™, Bubendorf et al. and Zellweger et al.

Results: In the diagnostic cohort, 228 patients (21.8%) had BC at time of evaluation; in the prognostic cohort 39 patients (32.0%) experienced tumor recurrence. Alterations in chromosome 3, 7 and 17 correlated with the presence of BC. Relative loss of 9p21 was associated with BC and higher risk for progression. The evaluation strategy proposed by Zellweger et al. showed highest accuracy of all FISH assessments. Performance of evaluation strategies differed in voided urine samples and samples obtained after mechanical manipulation.

Conclusions: The performance of FISH in BC diagnosis strongly depends on the interpretation criteria. Alternative evaluation methods partly show superior diagnostic performance compared to the manufacturer's algorithm. The introduction of specific cutoffs for tetraploid cells improves specificity. Further modifications of the interpretation algorithm of the Urovysion FISH assay have the potential to positively affect the value of this test in diagnosis and surveillance of BC.
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http://dx.doi.org/10.1007/s00432-016-2310-5DOI Listing
April 2017

Interdisciplinary consensus statement on indication and application of a hydrogel spacer for prostate radiotherapy based on experience in more than 250 patients.

Radiol Oncol 2016 Sep 19;50(3):329-36. Epub 2016 Jul 19.

Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany.

Background: The aim of the study was to reach a consensus on indication and application of a hydrogel spacer based on multicentre experience and give new users important information to shorten the learning curve for this innovative technique.

Methods: The interdisciplinary meeting was attended by radiation oncologists and urologists, each with experience of 23 - 138 hydrogel injections (SpaceOAR®) in prostate cancer patients before dose-escalated radiotherapy. User experience was discussed and questions were defined to comprise practical information relevant for successful hydrogel injection and treatment. Answers to the defined key questions were generated. Hydrogel-associated side effects were collected to estimate the percentage, treatment and prognosis of potential risks.

Results: The main indication for hydrogel application was dose-escalated radiotherapy for histologically confirmed low or intermediate risk prostate cancer. It was not recommended in locally advanced prostate cancer. The injection or implantation was performed under transrectal ultrasound guidance via the transperineal approach after prior hydrodissection. The rate of injection-related G2-toxicity was 2% (n = 5) in a total of 258 hydrogel applications. The most frequent complication (n = 4) was rectal wall penetration, diagnosed at different intervals after hydrogel injection and treated conservatively.

Conclusions: A consensus was reached on the application of a hydrogel spacer. Current experience demonstrated feasibility, which could promote initiation of this method in more centres to reduce radiation-related gastrointestinal toxicity of dose-escalated IGRT. However, a very low rate of a potential serious adverse event could not be excluded. Therefore, the application should carefully be discussed with the patient and be balanced against potential benefits.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5024663PMC
http://dx.doi.org/10.1515/raon-2016-0036DOI Listing
September 2016

Oncological Outcomes of Patients with Concomitant Bladder and Urethral Carcinoma.

Urol Int 2016 28;97(2):134-41. Epub 2016 Jul 28.

Department of Urology, University of Michigan, Ann Arbor, Mich., USA.

Introduction: The study aimed to investigate oncological outcomes of patients with concomitant bladder cancer (BC) and urethral carcinoma.

Methods: This is a multicenter series of 110 patients (74 men, 36 women) diagnosed with urethral carcinoma at 10 referral centers between 1993 and 2012. Kaplan-Meier analysis was used to investigate the impact of BC on survival, and Cox regression multivariable analysis was performed to identify predictors of recurrence.

Results: Synchronous BC was diagnosed in 13 (12%) patients, and the median follow-up was 21 months (interquartile range 4-48). Urethral cancers were of higher grade in patients with synchronous BC compared to patients with non-synchronous BC (p = 0.020). Patients with synchronous BC exhibited significantly inferior 3-year recurrence-free survival (RFS) compared to patients with non-synchronous BC (63.2 vs. 34.4%; p = 0.026). In multivariable analysis, inferior RFS was associated with clinically advanced nodal stage (p < 0.001), proximal tumor location (p < 0.001) and synchronous BC (p = 0.020).

Conclusion: The synchronous presence of BC in patients diagnosed with urethral carcinoma has a significant adverse impact on RFS and should be an impetus for a multimodal approach.
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http://dx.doi.org/10.1159/000448335DOI Listing
April 2017

Oncologic Impact of Renal Tissue Adjacent to Renal Cell Carcinoma.

Anticancer Res 2016 Jun;36(6):2865-9

Department of Urology, Eberhard Karls University Tübingen, Tübingen, Germany

Aim: The aim of the study was to investigate the clinical impact of the surgical margin width after nephron-sparing surgery (NSS) on the oncological course of renal cell carcinoma (RCC).

Patients And Methods: The study comprised of 126 RCC patients with NSS between 2002 and 2009. Inclusion criteria were negative resection margins and a tumor diameter of ≤100 mm with the possibility of a complete circumferential histopathological reevaluation. The minimal benign margin width was correlated to the patients' clinical course.

Results: Median safety margin width was revealed to be 1 mm. Nine of 126 patients (7.1%) developed recurrent disease (five local, four distant). All patients with local recurrence had safety margins ≤1 mm, whereas out of 49 patients with a margin >1 mm no one developed local recurrence (p=0.0245). Safety margin ≤1 mm showed associations with increased risk for overall recurrence in univariate and multivariate analysis (p=0.0531 and 0.0539, respectively).

Conclusion: Tumor adjacent renal parenchyma may have oncological relevance, corroborating the need for further molecular investigation of tumor-adjacent tissue in RCC.
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June 2016

Transcripts of circulating tumor cells detected by a breast cancer-specific platform correlate with clinical stage in bladder cancer patients.

J Cancer Res Clin Oncol 2016 May 24;142(5):1013-20. Epub 2016 Feb 24.

Department of Urology, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.

Purpose: There is increasing interest in circulating tumor cells (CTCs) as a biomarker in bladder cancer (BC). In the present pilot study, we used a platform originally developed for detection of breast cancer CTCs to assess breast cancer-associated transcripts in CTCs of patients with different stages of BC. Moreover, transcripts specific for cancer stem cells and epithelial mesenchymal transition (EMT) were assessed.

Methods: We prospectively enrolled 83 BC patients and 29 controls. The AdnaTest® system was used to enrich epithelial cells in peripheral blood and to detect breast cancer-associated, stem cell-specific or EMT-specific transcripts. Test results were correlated with clinical and pathological stage.

Results: A positive AdnaTest® BreastCancerDetect was present in 6.9 % of controls (group A), 6.7, 15.0 and 18.7 % of patients with non-muscle-invasive BC (B), cM0 muscle-invasive BC (C) and metastatic BC (D) (p = 0.13). Stem cell-specific transcripts in group A, B, C and D were detected in 10.3, 10.0, 22.5 and 31.3 % (p = 0.03). EMT-associated transcripts were present in 3.5, 3.3, 15.0 and 18.7 % (p = 0.03). In group C, epithelial and stem-like transcripts correlated with tumor stage (p = 0.01 and 0.04).

Conclusions: CTCs with expression of breast cancer-associated transcripts are present in a considerable proportion of patients with BC. EMT and stem cell-specific transcripts of CTCs correlate with clinical stage and can be detected in patients negative for epithelial transcripts. The prognostic relevance of AdnaTest® results in BC patients and potential implications for therapy decisions remain to be determined in prospective studies.
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http://dx.doi.org/10.1007/s00432-016-2129-0DOI Listing
May 2016

Prostate tumor overexpressed 1 expression in invasive urothelial carcinoma.

J Cancer Res Clin Oncol 2016 May 8;142(5):937-47. Epub 2016 Jan 8.

Department of Urology, University Hospital, Tübingen, Germany.

Purpose: To determine the expression patterns of the proliferation marker prostate tumor overexpressed 1 (PTOV1) in invasive urothelial cancer (UC).

Methods: Corresponding UC and benign samples from paraffin-embedded tissue of 102 patients treated with cystectomy for invasive UC were immunohistochemically (IHC) assessed for PTOV1. Expression was evaluated gradually separated for cytoplasmic and nuclear staining. Results were correlated to histological and clinical data. To correlate PTOV1 expression with molecular subtypes of UC, analysis of PTOV1 RNA expression data of the Cancer Genome Atlas UC cohort was performed.

Results: PTOV1 expression was present in UC and benign urothelium, whereby nuclear staining was significantly more frequent in UC tissue (p = 0.0004). Lower cytoplasmic expression was significantly associated with pathological stage >pT2 (p = 0.0014) and grade ≥G3 (p = 0.0041), respectively. IHC expression patterns did not show correlation to survival data. PTOV1 RNA expression correlated with features of the luminal UC subtype.

Conclusions: Subcellular distribution seems to be the most important feature of PTOV1 expression in UC. Nuclear localization of PTOV1 along with cytoplasmic decrease in PTOV1 expression was identified as putative surrogate for PTOV1-associated cellular proliferation and dedifferentiation in UC. The functional relevance as well as the potential role of PTOV1 as a biomarker in UC remains to be specified in future studies.
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http://dx.doi.org/10.1007/s00432-015-2107-yDOI Listing
May 2016

The prognostic role of pre-cystectomy hemoglobin levels in patients with invasive bladder cancer.

World J Urol 2016 Jun 29;34(6):829-34. Epub 2015 Sep 29.

Department of Urology, Eberhard-Karls University Tuebingen, Hoppe-Seyler Strasse 3, 72076, Tuebingen, Germany.

Purpose: To determine whether pre-treatment hemoglobin (Hb) levels in patients with bladder cancer impact on oncological outcomes after radical cystectomy (RC).

Methods: A consecutive, contemporary series of 246 patients undergoing RC and pelvic lymph node dissection for bladder cancer. Decreased Hb level was defined as ≤12 g/dL. The Kaplan-Meier method was used to estimate recurrence-free (RFS), cancer-specific (CSS) and overall survival (OS). The Fisher exact/Chi-square test was used to investigate differences between both groups. Uni- and multivariable Cox regression analysis addressed risk factors for recurrence, cancer-specific death and overall death. The median follow-up was 30 months (2-116).

Results: Of the 246 patients, 182 (74 %) had normal (>12 g/dL) and 64 decreased (≤12 g/dL) preoperative Hb (26 %). In univariable analysis, decreased Hb was associated with increased age, extravesical disease, hydronephrosis (all p < 0.001), node-positive disease and positive resection margins (both p = 0.01). Subanalyzed for patients with organ-confined disease (defined as ≤pT2bN0R0; N = 109), the 3-year RFS, CSS and OS was significantly lower in patients with decreased (34.9, 35.5 and 19.8 %) compared to normal Hb level (69.7, 86.3 and 77.6 %; p = 0.01/p = 0.002/p < 0.001). In multivariable analysis, RFS, CSS and OS were significantly lower in patients with decreased Hb (p = 0.007, p = 0.001 and p = 0.002), pathologically locally advanced tumor (≥pT3a; p = 0.023, p = 0.036 and p = 0.065) and nodal stage (p < 0.001, p = 0.006 and p = 0.001) and positive soft tissue surgical margins (p = 0.040, p = 0.004 and 0.012).

Conclusions: Pre-cystectomy Hb levels are associated with adverse histopathologic characteristics and provide additional prognostic information especially for patients with pathologically localized bladder cancer.
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http://dx.doi.org/10.1007/s00345-015-1693-2DOI Listing
June 2016

Muscle-invasive bladder cancer is characterized by overexpression of thymidine kinase 1.

Urol Oncol 2015 Oct 29;33(10):426.e21-9. Epub 2015 Jul 29.

Department of Urology, University Hospital, Eberhard-Karls-University, Tuebingen, Germany; Vancouver Prostate Centre, University of British Columbia, Vancouver, Canada. Electronic address:

Objective: Thymidine kinases have an important role in the synthesis of DNA and exhibit high activity in rapidly proliferating cells. Thymidine kinase 1 (TK1) activity has been shown to be increased in various cancer types and proposed as a prognostic parameter. Aim of the present study was to investigate TK1 in muscle-invasive urothelial carcinoma (UC).

Methods: Corresponding UC and benign samples from paraffin embedded tissue of 111 patients treated with cystectomy for invasive UC from 1996 to 2006 were immunohistochemically (IHC) assessed for TK1. IHC expression patterns were evaluated in a semiquantitative fashion by 2 independent reviewers. Localization of staining was categorized into pure nuclear and additional cytoplasmic localization. Uni- and multivariate analyses were performed to assess differential expression in normal and UC tissue and to evaluate the diagnostic and predictive capability of TK1 by correlation to clinical data. To correlate TK1 expression with molecular subtypes of UC, analysis of TK1 RNA expression levels of the Cancer Genome Atlas UC cohort was performed.

Results: TK1 was significantly overexpressed in invasive UC, compared to benign urothelium (P<0.0001), and cytoplasmic expression was more often found in cancer tissue than in benign tissue (P = 0.0001). No correlations of TK1 protein expression patterns to standard histopathological determinants were detected. In univariate analysis, TK1 nuclear and cytoplasmic expression was associated with improved cancer-specific survival (P = 0.0119). However, only metastasis status and histologic grade were identified as independent predictors of cancer-specific survival in multivariate analysis. TK1 expression was merely found in the basal layers of benign urothelium. RNA overexpression of TK1 could be correlated to the biologically more aggressive basal UC subtype.

Conclusions: TK1 expression is significantly different in invasive UC and benign urothelium, which underlines its potential as a diagnostic marker. Although TK1 is considered to be a marker of proliferation, and TK1 RNA overexpression is associated with an aggressive UC subtype, its capability as a predictive IHC biomarker for invasive UC remains limited.
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http://dx.doi.org/10.1016/j.urolonc.2015.06.007DOI Listing
October 2015

Inflammation and Cancer: What Can We Therapeutically Expect from Checkpoint Inhibitors?

Curr Urol Rep 2015 Sep;16(9):59

Department of Urology, Eberhard-Karls University Tübingen, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany.

Programmed death-ligand 1 (PD-L1) is a cell surface protein which is mainly expressed on immune cells as well as on cancer cells and functions as a co-stimulatory molecule for T lymphocytes. It is capable of inducing apoptosis in T-cells via PD-1 which leads to impaired cytokine production and loss of cytotoxicity of activated T-cells. This represents a possible escape mechanism for cancer cells. Tumor infiltration by mononuclear cells and tumor aggressiveness was found to be associated with PD-L1 expression. In light of possible autoimmunological side effects, it remains currently unclear which patient will benefit most from this novel therapeutic approach. Furthermore, immunohistochemistry for PD-L1 has not been well standardized until now. In addition, the combination of chemotherapy with checkpoint inhibitors in different clinical settings needs to be established for the near future in order to avoid overtreatment and also unnecessary cost expenditures for the health care system.
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http://dx.doi.org/10.1007/s11934-015-0532-8DOI Listing
September 2015

Prognostic factors and outcomes in primary urethral cancer: results from the international collaboration on primary urethral carcinoma.

World J Urol 2016 Jan 17;34(1):97-103. Epub 2015 May 17.

USC/Norris Comprehensive Cancer Center, Institute of Urology, Los Angeles, CA, USA.

Purpose: To evaluate risk factors for survival in a large international cohort of patients with primary urethral cancer (PUC).

Methods: A series of 154 patients (109 men, 45 women) were diagnosed with PUC in ten referral centers between 1993 and 2012. Kaplan-Meier analysis with log-rank test was used to investigate various potential prognostic factors for recurrence-free (RFS) and overall survival (OS). Multivariate models were constructed to evaluate independent risk factors for recurrence and death.

Results: Median age at definitive treatment was 66 years (IQR 58-76). Histology was urothelial carcinoma in 72 (47 %), squamous cell carcinoma in 46 (30 %), adenocarcinoma in 17 (11 %), and mixed and other histology in 11 (7 %) and nine (6 %), respectively. A high degree of concordance between clinical and pathologic nodal staging (cN+/cN0 vs. pN+/pN0; p < 0.001) was noted. For clinical nodal staging, the corresponding sensitivity, specificity, and overall accuracy for predicting pathologic nodal stage were 92.8, 92.3, and 92.4 %, respectively. In multivariable Cox-regression analysis for patients staged cM0 at initial diagnosis, RFS was significantly associated with clinical nodal stage (p < 0.001), tumor location (p < 0.001), and age (p = 0.001), whereas clinical nodal stage was the only independent predictor for OS (p = 0.026).

Conclusions: These data suggest that clinical nodal stage is a critical parameter for outcomes in PUC.
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http://dx.doi.org/10.1007/s00345-015-1583-7DOI Listing
January 2016

Robot-assisted radical cystectomy and intracorporeal urinary diversion - safe and reproducible?

Cent European J Urol 2015 31;68(1):18-23. Epub 2014 Dec 31.

Department of Urology, Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training & Research Hospital, Ankara, Turkey.

Introduction: Robot-assisted radical cystectomy (RARC) plus intracorporeal urinary diversion is feasible. Few centers worldwide demonstrated comparable functional and oncologic outcomes. We reported a large series of RARC and intracorporeal diversion to assess its feasibility and reproducibility.

Material And Methods: We identified 101 RARCs in 82 men and 19 women (mean age 68.3 years) from October 2009 to October 2014. The patients underwent RARC and pelvic lymphadenectomy followed by intracorporeal urinary diversion (ileal conduit/ neobladder). Out of the 101 patients, 28 (27.7%) received intracorporeal ileal conduits and 73 (72.3%) intracorporeal neobladders. Studer pouch was performed in all the patients who underwent intracorporeal neobladder formation. Perioperative, functional and oncologic results including CSS and OS are reported.

Results: Mean operative time was 402.3 minutes (205-690) and blood loss was 345.3 ml (50-1000). The mean hospital stay was 17.1 days (5-62). All the surgeries were completed with no open conversion. Minor complications (Grade I and II) were reported in 27.7% of patients while major complications (grade III and above) were reported in 36.6% of patients. The mean nodal yield was 20.6 (0-46). Positive ureteric margins were found in 8.9% of patients. The average follow-up was 27.5 months (1-52). Daytime continence could be achieved in 89.2% of patients who underwent intracorporeal neobladder. The 3-year cancer specific survival (CSS) and overall survival (OS) was 80.2% and 69.8% respectively.

Conclusions: RARC with intracorporeal diversion is safe and reproducible in 'non-pioneer' tertiary centers with robotic expertise having acceptable operative time and complications as well as comparable functional and oncologic outcomes.
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http://dx.doi.org/10.5173/ceju.2015.01.466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408389PMC
April 2015

Intracorporeal ileal ureter replacement using laparoscopy and robotics.

Cent European J Urol 2014 5;67(4):420-3. Epub 2014 Dec 5.

Department of Urology, Eberhard-Karls University, Tuebingen, Germany.

Introduction: Ileal ureter is a suitable treatment option for patients with long ureteric strictures. Minimally invasive techniques have been shown to be as safe as open techniques but superior in terms of post-operative recovery. We report our experience using minimally invasive techniques for total intracorporeal ureteral replacement.

Material And Methods: A chart review revealed five patients who underwent intracorporeal ileal ureter using minimally invasive techniques in the preceding 5 years. 4 patients underwent conventional laparoscopic surgery and 1 patient underwent robotic-assisted surgery. Patient's characteristics, perioperative data and functional outcomes as well as a detailed description of surgical technique are reported. In all 5 of these patients, the ileal ureter was performed completely intracorporeally.

Results: The median age of our patients is 61 (range 42-73). The median operative time was 250 minutes (range 150-320) and median blood loss was 100 ml (range 50-200). The median hospital stay was 8 days (range 6-10) and there were no major perioperative complications reported. At median follow up of 22 months (range 4-38), there were no recurrences of strictures or any other complications.

Conclusions: We have demonstrated the safety and feasibility of minimally invasive intracorporeal ileal ureter. Numbers are still small but its application is likely to grow further.
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http://dx.doi.org/10.5173/ceju.2014.04.art21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4310887PMC
February 2015

Fluorescence-guided bladder tumour resection: impact on survival after radical cystectomy.

World J Urol 2015 Oct 17;33(10):1429-37. Epub 2015 Jan 17.

Department of Urology, Eberhard-Karls University, Hoppe-Seyler Strasse 3, 72076, Tuebingen, Germany.

Purpose: To investigate whether photodynamic diagnosis (PDD)-guided bladder tumour resection (TUR-BT) is of prognostic value in patients undergoing subsequent radical cystectomy (RC) for bladder cancer (BC).

Methods: In 224 consecutive patients who underwent RC and bilateral pelvic lymphadenectomy for BC between 2002 and 2010 (median follow-up 29 months [IQR 8-59]), we retrospectively investigated whether patients had previously undergone PDD-guided (hexaminolevulinate [HAL] vs. 5-aminolevulinate [ALA]) versus white light (WL)-TUR-BT. Kaplan-Meier analysis was used to estimate recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) using log-rank and Cox regression model for uni- and multivariable analysis.

Results: Of the 224 patients, 66 (29.5 %) underwent HAL-, 23 (10.3 %) ALA- and 135 (60.2 %) WL-TUR-BT before RC. The 3-year RFS/CSS/OS was 77.8/83.9/74.0 % for HAL-, 53.6/74.5/60.9 % for ALA- and 52.4/59.7/56.5 % for WL-TUR-BT (p = 0.002/0.023/0.037 for HAL vs. WL/ALA). PDD-TUR-BT was associated with a higher number of TUR-BTs before RC (p < 0.001) and re-resections (p = 0.015), a longer time between the first TUR-BT and RC (p = 0.044) and a lower rate of post-operative systemic chemotherapy (p = 0.001). In multivariable analysis, performance of HAL-TUR-BT, pathologic tumour and nodal stage as well as soft tissue surgical margin status were independent predictors for RFS, CSS and OS.

Conclusions: This series indicates for the first time that HAL-guided TUR-BT is an independent predictor for improved survival after RC.
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http://dx.doi.org/10.1007/s00345-015-1485-8DOI Listing
October 2015

Stepwise application of urine markers to detect tumor recurrence in patients undergoing surveillance for non-muscle-invasive bladder cancer.

Dis Markers 2014 22;2014:973406. Epub 2014 Dec 22.

Department of Urology, Eberhard-Karls University, Hoppe-Seyler Strasse 3, 72076 Tübingen, Germany.

Background: The optimal use of urine markers in the surveillance of non-muscle-invasive bladder cancer (NMIBC) remains unclear. Aim of the present study was to investigate the combined and stepwise use of the four most broadly available urine markers to detect tumor recurrence in patients undergoing surveillance of NMIBC.

Patients And Methods: 483 patients with history of NMIBC were included. Cytology, UroVysion, fluorescence in situ hybridization (FISH), immunocytology (uCyt+), and NMP22 ELISA were performed before surveillance cystoscopy. Characteristics of single tests and combinations were assessed by contingency analysis.

Results: 128 (26.5%) patients had evidence of tumor recurrence. Sensitivities and negative predictive values (NPVs) of the single tests ranged between 66.4-74.3 and 82.3-88.2%. Two-marker combinations showed sensitivities and NPVs of 80.5-89.8 and 89.5-91.2%. A stepwise application of the two-test combinations with highest accuracy (cytology and FISH; cytology and uCyt+; uCyt+ and FISH) showed NPVs for high-risk recurrences (G3/Cis/pT1) of 98.8, 98.8, and 99.1%, respectively.

Conclusions: Combinations of cytology, FISH, immunocytology, and NMP22 show remarkable detection rates for recurrent NMIBC. Stepwise two-test combinations of cytology, FISH, and immunocytology have a low probability of missing a high-risk tumor. The high sensitivities may justify the use of these combinations in prospective studies assessing the use of urine markers to individualize intervals between cystoscopies during follow-up.
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http://dx.doi.org/10.1155/2014/973406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4284969PMC
July 2015

Significance of apoptotic and non-apoptotic disseminated tumor cells in the bone marrow of patients with clinically localized prostate cancer.

Prostate 2015 May 13;75(6):637-45. Epub 2015 Jan 13.

Department of Urology, University Hospital, Tübingen, Germany; Vancouver Prostate Centre, University of British Columbia, Vancouver, Canada.

Background: Disseminated tumor cells (DTC) can be detected in a high proportion of patients with localized solid malignancies. In prostate cancer (PC), determination of DTCs is critically discussed as there are conflicting results on their prognostic value. The aim of the present study was to evaluate the presence and prognostic role of DTCs in PC patients with a high risk of disease recurrence.

Methods: 248 patients with clinically localized PC undergoing radical prostatectomy with features of increased risk of recurrence (PSA ≥10 ng/ml or Gleason score ≥ 4 + 3 = 7 or pT ≥3) were included. All patients underwent intraoperative bone marrow (BM) aspiration biopsy. BM cells were evaluated by immunocytochemistry for cytokeratines and the apoptosis marker caspase-cleaved cytokeratin 18 (M30). Results of immunocytochemistry were correlated with clinical and pathological parameters and clinical outcome of the patients.

Results: Of 248 patients, 47 (19.0%) had evidence of DTCs at time of radical prostatectomy. In 17 of these 47 patients (36.2%), DTCs expressed the apoptosis marker M30. We observed no correlation between the presence of DTCs and tumor stage, nodal stage, prostate-specific antigen, or Gleason score. After a median-follow-up of 58 months (23-76), no differences in rates of biochemical recurrence, development of metastases and cancer-specific death were observed between patients with and without DTCs while apoptosis markers had no role.

Conclusions: In a single-centre cohort of patients with increased risk for disease recurrence, the presence of DTCs at the time of prostatectomy does not influence clinical outcome. For the first time in patients with PC, DTCs were evaluated for immunocytological features indicating apoptosis. Due to conflicting results of studies on DTCs, BM biopsies at time of radical prostatectomy cannot be recommended as a standard procedure in patients with clinically localized PC.
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http://dx.doi.org/10.1002/pros.22947DOI Listing
May 2015

Robot-assisted radical cystectomy and intracorporeal neobladder formation: on the way to a standardized procedure.

World J Surg Oncol 2015 Jan 6;13. Epub 2015 Jan 6.

Department of Urology, Ankara Atatürk Training & Research Hospital, Ankara, Turkey.

Background: Robot-assisted radical cystectomy (RARC) with intracorporeal diversion has been shown to be feasible in a few centers of excellence worldwide, with promising functional and oncologic outcomes. However, it remains unknown whether the complexity of the procedure allows its duplication in other non-pioneer centers. We attempt to address this issue by presenting our cumulative experience with RARC and intracorporeal neobladder formation.

Methods: We retrospectively identified 62 RARCs in 50 men and 12 women (mean age 63.6 years) in two tertiary centers. Intracorporeal Studer neobladders were created, duplicating the steps of standard open surgery. Perioperative and postoperative variables and complications were analyzed using standardized tools. Functional and oncological results were assessed.

Results: The mean operative time was 476.9 min (range, 310 to 690) and blood loss was 385 ml (200 to 800). The mean hospital stay was 16.7 (12 to 62) days with no open conversion. Perioperative complications were grade II in 15, grade III in 11, and grade IV in 5 patients. The mean nodal yield was 22.9 (8 to 46). Positive margins were found in in 6.4%. The 90- and 180-day mortality rates were 0% and 3.3%. The average follow-up was 37.3 months (3 to 52). Continence was achieved in 88% of patients. The cancer-specific survival rate and overall survival rate were 84% and 71%, respectively.

Conclusions: A RARC with intracorporeal neobladder creation is safe and reproducible in 'non-pioneer' tertiary centers with robotic expertise with acceptable operative time and complications. Further standardization of RARC with intracorporeal diversion is a prerequisite for its widespread use.
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http://dx.doi.org/10.1186/1477-7819-13-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4326337PMC
January 2015

Quality of life outcomes after radical cystectomy: long-term standardized assessment of Studer Pouch versus I-Pouch.

World J Urol 2015 Oct 11;33(10):1381-7. Epub 2014 Dec 11.

Department of Urology, University Hospital Tübingen, Eberhard-Karls University, Hoppe-Seyler Street 3, 72076, Tübingen, Germany.

Purpose: To investigate whether the ileal length used for the formation of two different orthotopic bladder substitutes [Studer (S)-Pouch vs. I-Pouch; 60 vs. 40 cm] impacts quality of life (QoL).

Materials And Methods: In this cross-sectional study, a total of 56 patients underwent radical cystectomy with ileal neobladder for bladder cancer [S-Pouch: 23 pat, 19 men, 4 women); I-Pouch: 33 pat (26 men, 7 women)]. They completed general (SF-36), cancer-specific (QLQ-C30) and bladder cancer-specific questionnaires (QLQ-BLM30) as well as a novel neobladder-specific questionnaire (TNQ). The questionnaire-based follow-up was 66 months (IQR 41-104; total range 9-161).

Results: I-Pouch patients reported better SF-36 physical health status (p = 0.026), QLQ-BLM30 continence scores (p < 0.001) and a more favorable QLQ-C30 total score compared to S-Pouch patients (p = 0.044). S-Pouch patients reported better QLQ-BLM30 general health status (p = 0.001). For the TNQ, no significant difference was found between both groups (p = 0.09). S-Pouch patients reported use of condom urinals more frequently (p = 0.026). S-Pouch patients tended to be on vitamin B12 substitution (p = 0.06). I-Pouch patients reported significantly higher micturition volumes (≥300 ml) compared to S-Pouch patients (30/33 vs. 16/23; p = 0.040). No differences were found with regard to bicarbonate supplementation and recurrent urinary tract infections.

Conclusion: Non-neobladder-specific questionnaires show controversial results for QoL outcomes of patients with Studer and I-Pouch. The TNQ suggests that none of these two types of neobladder is superior to the other in terms of QoL. Hence, general questionnaires are not valid enough to adequately address QoL aspects in patients with different neobladders. Development and validation of neobladder-specific questionnaires are needed.
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http://dx.doi.org/10.1007/s00345-014-1461-8DOI Listing
October 2015

Y pouch neobladder-a simplified method of intracorporeal neobladder after robotic cystectomy.

J Endourol 2015 Apr 10;29(4):387-9. Epub 2014 Oct 10.

1 Department of Urology, Eberhard-Karls-University , Tübingen, Germany .

In recent years, robot-assisted radical cystectomy (RARC) has shown similar oncologic outcomes compared with the gold standard open radical cystectomy with the added benefit of less blood loss and shorter hospital stay. Robot-assisted cystectomy with intracorporeal ileal neobladder is a complex surgical procedure and is usually performed in centers with experienced surgeons. We propose robot-assisted cystectomy with intracorporeal neobladder using the Y pouch previously described in open radical cystectomy. We think that the Y pouch is easier to perform than conventional spherical pouches without compromising functional outcomes. It may therefore be a good alternative for patients undergoing RARC with intracorporeal diversion.
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http://dx.doi.org/10.1089/end.2014.0507DOI Listing
April 2015

Totally intracorporeal replacement of the ureter using whole-mount ileum.

J Endourol 2014 Oct 5;28(10):1165-7. Epub 2014 Jun 5.

Department of Urology, Eberhard-Karls University Tuebingen , Germany .

Ileal ureter is a suitable treatment option for patients with long ureteral strictures. Minimally invasive techniques have been shown to be as safe as open technique and superior in terms of postoperative recovery. We report the first case of laparoscopic totally intracorporeal replacement of ureter using whole-mount ileum in a patient with right-sided long ureteral stricture. The operative time was 150 minutes, and there were no complications. We have demonstrated the safety and feasibility of laparoscopic intracorporeal ileal ureter with possible advantage of shorter operative time compared with the robotic-assisted technique reported recently.
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http://dx.doi.org/10.1089/end.2014.0169DOI Listing
October 2014

Postchemotherapy laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell tumors infiltrating the great vessels.

J Endourol 2014 Jun 14;28(6):668-74. Epub 2014 Feb 14.

Department of Urology, Eberhard Karls University , Tübingen, Germany .

Background And Purpose: Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is an alternative in patients with metastatic nonseminomatous germcell tumors (NSGCT) necessitating resection of residuals postchemotherapy. With the advancement of laparoscopic vascular surgery, prospective management of the great vessels has become feasible and safe. We present our experience with L-RPLND in NSGCT residuals with significant vascular involvement necessitating intracorporeal reconstruction.

Patients And Methods: We have retrospectively identified 19 NSGCT patients (mean age 27 years) who presented with residuals postchemotherapy. A bilateral L-RPLND was performed in all men. Infiltration of the great vessels was confirmed intraoperatively. Prospective vascular control and temporary clamping was performed in all cases. The vessel wall was reconstructed using vascular surgery techniques. All patients had at least clinical stages of IIA or higher. Follow-up was obtained in all.

Results: There were no conversions to open surgery. The mean size of the residuals after chemotherapy was 3.87 cm (1.5-9.7 cm). The mean blood loss was 310 mL (50-1000 mL). Mean hospital stay was 6 days (3-9 days). There were no perioperative complications exceeding grade II according to the Clavien-Dindo classification. Distant or in-field recurrence (mean observational period 18 months) did not develop in any patient.

Conclusion: Laparoscopic RPLND may be considered a safe alternative concept for the management of post-chemotherapy NSGCT residuals involving the great vessels. Bilateral L-RPLND in patients with vascular infiltration is feasible and reproducible when laparoscopic vascular surgery can be reliably handled. All standard principles of open surgery are respected, and initial oncologic results are promising.
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http://dx.doi.org/10.1089/end.2013.0755DOI Listing
June 2014