Publications by authors named "Stephan Buse"

27 Publications

  • Page 1 of 1

Surgical benchmarks, mid-term oncological outcomes, and impact of surgical team composition on simultaneous enbloc robot-assisted radical cystectomy and nephroureterectomy.

BMC Urol 2021 Apr 28;21(1):73. Epub 2021 Apr 28.

Department of Urology and Paediatric Urology, University Medical Center, Johannes-Gutenberg-University, Mainz, Germany.

Background: Simultaneous urothelial cancer manifestation in the lower and upper urinary tract affects approximately 2% of patients. Data on the surgical benchmarks and mid-term oncological outcomes of enbloc robot-assisted radical cystectomy and nephro-ureterectomy are scarce.

Methods: After written informed consent was obtained, we prospectively enrolled consecutive patients undergoing enbloc radical cystectomy and nephro-ureterectomy with robotic assistance from the DaVinci Si-HD® system in a prospective institutional database and collected surgical benchmarks and oncological outcomes. Furthermore, as one console surgeon conducted all the procedures, whereas the team providing bedside assistance was composed ad hoc, we assessed the impact of this approach on the operative duration.

Results: Nineteen patients (9 women), with a mean age of 73 (SD: 7.5) years, underwent simultaneous enbloc robot-assisted radical cystectomy and nephro-ureterectomy. There were no cases of conversion to open surgery. In the postoperative period, we registered 2 Clavien-Dindo class 2 complications (transfusions) and 1 Clavien-Dindo class 3b complication (port hernia). After a median follow-up of 23 months, there were 3 cases of mortality and 1 case of metachronous urothelial cancer (contralateral kidney).The total operative duration did not decrease with increasing experience (r = 0.174, p = 0.534). In contrast, there was a significant, inverse, strong correlation between the console time relative to the total operative duration and the number of conducted procedures after adjusting for the degree of adhesions and the type of urinary diversion(r = -0.593, p = 0.02).

Conclusions: These data suggest that en bloc simultaneous robot-assisted radical cystectomy and nephro-ureterectomy can be safely conducted with satisfactory mid-term oncological outcomes. With increasing experience, improved performance was detectable for the console surgeon but not in terms of the total operative duration. Simulation training of all team members for highly complex procedures might be a suitable approach for improving team performance.

Trial Registration: Not applicable. Video Abstract.
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http://dx.doi.org/10.1186/s12894-021-00839-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082848PMC
April 2021

To defer or not to defer? A German longitudinal multicentric assessment of clinical practice in urology during the COVID-19 pandemic.

PLoS One 2020 15;15(9):e0239027. Epub 2020 Sep 15.

Department of Urology, Asklepios Klinik Altona, Hamburg, Germany.

Introduction: After the outbreak of COVID-19 unprecedented changes in the healthcare systems worldwide were necessary resulting in a reduction of urological capacities with postponements of consultations and surgeries.

Material And Methods: An email was sent to 66 urological hospitals with focus on robotic surgery (RS) including a link to a questionnaire (e.g. bed/staff capacity, surgical caseload, protection measures during RS) that covered three time points: a representative baseline week prior to COVID-19, the week of March 16th-22nd and April 20th-26th 2020. The results were evaluated using descriptive analyses.

Results: 27 out of 66 questionnaires were analyzed (response rate: 41%). We found a decrease of 11% in hospital beds and 25% in OR capacity with equal reductions for endourological, open and robotic procedures. Primary surgical treatment of urolithiasis and benign prostate syndrome (BPS) but also of testicular and penile cancer dropped by at least 50% while the decrease of surgeries for prostate, renal and urothelial cancer (TUR-B and cystectomies) ranged from 15 to 37%. The use of personal protection equipment (PPE), screening of staff and patients and protection during RS was unevenly distributed in the different centers-however, the number of COVID-19 patients and urologists did not reach double digits.

Conclusion: The German urological landscape has changed since the outbreak of COVID-19 with a significant shift of high priority surgeries but also continuation of elective surgical treatments. While screening and staff protection is employed heterogeneously, the number of infected German urologists stays low.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239027PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491711PMC
September 2020

Cost-effectiveness analysis of robot-assisted vs. open partial nephrectomy.

Int J Med Robot 2018 Aug 28;14(4):e1920. Epub 2018 May 28.

Department of Urology and Pediatric Urology, University Medical Center, Johannes-Gutenberg-University, Mainz, Germany.

Background: The cost-effectiveness of robot-assisted partial nephrectomy (RAPN) vs. the open procedure is not established.

Methods: We estimated in-hospital complications and the cost of RAPN vs. open partial nephrectomy (OPN) using an economic model. Costs incurred both intraoperatively and in hospital were considered. US data were extracted from existing literature.

Results: Mean in-hospital costs were $14,824 (95% CI $13,368-$16,898) for RAPN and $15,094 (95% CI $13,491-$17,140) for OPN. Complications after RAPN occurred in 23.3% (95% CI 20.0-25.8%) and after OPN in 36.1% (95% CI 35.6-36.6%) of the patients. In a sensitivity analysis, limited centre experience was associated with relevant increase in RAPN cost and consequently in low cost-effectiveness.

Conclusions: In this economic model based on US data, RAPN resulted in nominally lower cost but fewer perioperative complications than OPN. RAPN was not cost-effective in less experienced centres.
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http://dx.doi.org/10.1002/rcs.1920DOI Listing
August 2018

Sensation of Cold during the Ice Water Test Corresponds to the Perception of Pain during Botulinum Toxin Bladder Wall Injections.

Urol Int 2018 18;100(2):193-197. Epub 2018 Jan 18.

KontinenzZentrum Hirslanden, Zurich, Switzerland.

Aims: To investigate the association of bladder cold sensation (BCS) during the ice water test (IWT) and pain perception when botulinum toxin injections (BTI) are administered into the bladder wall.

Material And Methods: In 86 patients with idiopathic overactive bladder, the BCS during the IWT was investigated. Patients were divided into 2 groups: with and without BCS. During subsequent administration of BTI, the number of perceived and painful injections as well as the pain levels on a 0-100 pain scale were compared in both groups using Student t test.

Results: Thirty-five patients reported a BCS, while 51 did not. After 10 BTI, the mean number of perceived injections was 7.9 in patients with and 2.4 in patients without BCS (p < 0.0001). The mean number of painful injections was 5.4 in patients with BCS and 4.3 in patients without (p < 0.001). Mean levels on a 0-100 pain scale were 33.7 in patients with and 17.8 in patients without cold sensation (p < 0.0001).

Conclusion: The association of BCS during the IWT and pain to during BTI may implicate that the perceptions of cold and pain in the urinary bladder may use similar receptors and neuronal pathways.
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http://dx.doi.org/10.1159/000479167DOI Listing
September 2018

[Bipolar stimulation may improve the efficacy of the percutaneous nerve evaluation test of sacral neuromodulation].

Aktuelle Urol 2017 May 26;48(3):238-242. Epub 2017 Apr 26.

Urologische Klinik und Poliklinik, Universitätsklinikum der Johannes Gutenberg Universität, Mainz.

 This study evaluates the hypothesis that bipolar stimulation of the S3 and S4 sacral roots may enhance the efficacy of the percutaneous nerve evaluation (PNE) test.  In this case-control-study, we enrolled 43 patients undergoing bipolar PNE and 57 controls undergoing unipolar PNE. For bipolar PNE, four test electrodes were placed at the bilateral S3 and S4 roots. The electrodes at the S3 and S4 roots of each side were connected to obtain bipolar stimulation. The test protocol over eight days included unilateral and bilateral stimulation of the S3 and S4 sacral roots. Eight days after implantation, the electrodes were removed and test results from bladder diaries were collected.  The unipolar test procedure was successful in 47 % (27/57) of cases. The bipolar test procedure was successful in 58 % (25/43). In the bipolar group, 63 % (12/19) of patients with neurogenic tract dysfunction profited from treatment, vs. 57 % (13/23) in the unipolar group. Patients without a neurologic disease had a successful test in 58 % (14/24) of cases treated with bipolar PNE vs. 41 % (14/24) treated with unipolar PNE. Multivariate analysis did not reveal a statistically significant difference between groups.  Although not significant in this population, bipolar PNE may improve efficacy compared to the unipolar test procedure. Similar observations were made in subgroups of neurogenic and non-neurogenic bladder dysfunctions.
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http://dx.doi.org/10.1055/s-0042-121291DOI Listing
May 2017

First use of KORING to prevent parastomal hernia in robot-assisted ileal conduit formation.

Int J Urol 2016 08 14;23(8):710-1. Epub 2016 Jun 14.

Department of Urology and Urologic Oncology, Alfried Krupp Hospital, Essen, Germany.

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http://dx.doi.org/10.1111/iju.13127DOI Listing
August 2016

Simultaneous en-bloc robot-assisted radical cystectomy and nephro-ureterectomy: technique description, outcomes, and literature summary.

J Robot Surg 2016 Dec 6;10(4):315-322. Epub 2016 May 6.

Department of Urology, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany.

The objectives of this study are to describe the surgical technique for simultaneous en-bloc robot-assisted radical cystectomy and nephro-ureterectomy, to report its surgical bench marks, and finally, to summarize the current evidence on the procedure. After written informed consent, we prospectively enrolled consecutive patients undergoing simultaneous en-bloc robot-assisted radical cystectomy and nephro-ureterectomy in a prospective institutional database. We performed all procedures with robotic assistance from the DaVinci Si-HD, a four-arm robotic system. Endpoints included surgery duration, estimated intra-operative blood loss, resection margins, intra-, and post-operative complications. Furthermore, we describe oncological outcome at follow-up. We conducted six (54.4 %) right-sided and five (45.5 %) left-sided nephro-ureterectomies. Urinary diversion consisted in nine (81.2 %) ureterocutaneostomies and in two (18.8 %) ileum conduits. The median surgery duration was 287 min [interquartile range (Q1-Q3) 253-328], thereof 196-min console time (Q1-Q3 158-230). The median-estimated blood loss was 235 mL (Q1-Q3 200-262). We did not register any intra-operative complications or conversions to open surgery. Post-operatively, each one patient suffered a Clavien-Dindo grade 1 (paralytic ileus), grade 2 (blood transfusion), and grade 3 complication (port hernia). After a median follow-up of 7 months (Q1-Q3 4-25), we registered one recurrence, a metachronous transitional cell cancer of the contralateral kidney 24 months after the initial procedure. En-bloc robot-assisted radical cystectomy and nephro-ureterectomy was associated with limited procedure duration, minor blood loss and satisfying intra- and post-operative outcomes.
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http://dx.doi.org/10.1007/s11701-016-0600-1DOI Listing
December 2016

Cost-effectiveness of robot-assisted partial nephrectomy for the prevention of perioperative complications.

World J Urol 2016 Aug 12;34(8):1131-7. Epub 2015 Dec 12.

Department of Urology and Pediatric Urology, University Hospital of Frankfurt, Frankfurt, Germany.

Purpose: To evaluate the cost-effectiveness of robot-assisted partial nephrectomy (RAPN) and secondarily of laparoscopic PN (LPN) compared to the open procedure.

Methods: Model-based cost-effectiveness analysis: The model was structured as decision tree. The model was populated with published data. We measured intraoperative, postoperative complications, and inhospital deaths. We expressed costs in US dollars ($).The reference analysis calculated the mean cost and the mean number of each endpoint over 5000 iterations using a second-order Monte Carlo simulation. We conducted extensive sensitivity analyses.

Results: The mean inhospital costs were $13,186 for RAPN, $10,782 for LPN, and $12,539 for open partial nephrectomy (OPN), respectively. The incremental cost to prevent an inhospital event amounted to $5005 for RAPN compared to OPN. Lower RENAL scores were associated with lower incremental cost per avoided complications. Under assumption of 55 % higher costs in patients with complications, RAPN dominated OPN. LPN dominated OPN. We are aware of the following limitations: First, cost data for patients with and without complications were not available and we assumed the median cost for all cases, i.e., the analysis overestimated the cost associated with RAPN; second, we focused on inhospital estimates and did not apply a societal perspective.

Conclusions: RAPN appears to be a cost-effective mean to avoid inhospital complications; however, these results might not apply to low-volume hospitals or to other health care systems.
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http://dx.doi.org/10.1007/s00345-015-1742-xDOI Listing
August 2016

Midterm results of robot-assisted sacrocolpopexy.

Int Urogynecol J 2015 Sep 8;26(9):1321-6. Epub 2015 Apr 8.

Department of Urology, Alfried Krupp Krankenhaus, Essen, Germany.

Introduction And Hypothesis: Robotic assistance simplifies laparoscopic procedures. We hypothesize that robot-assisted sacrocolpopexy is a rapid and safe procedure with satisfying short-term and midterm functional results.

Methods: After informed consent, we enrolled 101 consecutive patients undergoing sacrocolpopexy at Alfried Krupp Hospital, Essen, Germany. After a median follow-up of 22 months, we assessed midterm functional results as the primary endpoint. Secondary endpoints included surgical duration, blood loss, intraoperative complications, and postoperative complications. We described frequencies as counts (percent) and continuous data as median [interquartile range (Q1-Q3)] or mean [standard deviation (SD)], as appropriate.

Results: We enrolled 101 patients. The mean age was 69 years (SD 11); 75 women (74.3 %) had undergone previous abdominal surgery. Among the patients, 95 (94.1 %) presented with anterior vaginal wall prolapse Baden-Walker grade 2-3, 74 (73.3 %) vaginal vault prolapse, and 9 (8.9 %) concomitant rectocele. Fifty (50 %) patients underwent a modified Burch procedure in addition to sacrocolpopexy. The median surgical duration was 96 min (Q1-Q3 83-130). There were six (5.9 %) minor intraoperative complications but no conversions to open surgery. Postoperatively, we registered five (4.9 %) Clavien-Dindo grade I complications, three (3.0 %) grade II complications, and one (1.0 %) grade III complication. After a median follow-up of 22 months (Q1-Q3 12-49), the patients reported significant decreased impact of pelvic organ prolapse (POP) on quality of life as well as bother resulting from POP symptoms. The overall success rate, defined as none or minor impact of POP on quality of life, was 75 %.

Conclusions: In this single-surgeon study, robot-assisted sacrocolpopexy was a safe and rapidly performed procedure that achieved good medium-term functional results.
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http://dx.doi.org/10.1007/s00192-015-2688-7DOI Listing
September 2015

Treatment algorithm for metastatic renal cell carcinoma--recommendations based on evidence and clinical practice.

Oncol Res Treat 2014 21;37(3):136-41. Epub 2014 Feb 21.

Medizinische Klinik II, Universitätsklinik Frankfurt, Frankfurt am Main, Germany.

Until a few years ago, the treatment options for metastatic renal cell cancer (mRCC) were very limited. The growing understanding of the molecular pathomechanisms underlying RCC allowed the development of new treatment approaches. Meanwhile, several approved target-oriented substances from different drug classes are available for mRCC. The mechanism of action of vascular endothelial growth factor (VEGF) and VEGF receptor or mTOR inhibition is well documented by phase III trials and reflected in the current guidelines. However, no predictive biomarkers have been identified in mRCC so far to demonstrate a benefit by a specific compound in an individual patient. Meanwhile, the sequential use of 'targeted therapies' in mRCC has been established as standard treatment. The optimal sequence of available agents is still unclear. A German RCC expert panel discussed and developed an algorithm for the choices of first- and second-line treatment in mRCC based on established clinical criteria.
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http://dx.doi.org/10.1159/000360179DOI Listing
December 2014

Characterization and risk stratification of prostate cancer in patients undergoing radical cystoprostatectomy.

Int J Urol 2013 Sep 4;20(9):866-71. Epub 2013 Feb 4.

Department of Urology, University of Heidelberg, Heidelberg, Germany.

Objective: To describe the prevalence of incidental prostate cancer in patients undergoing radical cystoprostatectomy for bladder malignancy; to quantify the association between incidental prostate cancer and mortality in these patients; and to quantify the association between incidental prostate cancer and age in radical cystoprostatectomy specimens.

Methods: Consecutive patients undergoing radical cystoprostatectomy for bladder malignancy at six academic institutions were assessed. End-points were the histological diagnosis of prostate cancer in the radical cystoprostatectomy specimens and mortality. The association between incidental prostate cancer and mortality was calculated by multivariable Cox regression, and the association between age and the occurrence of prostate cancer was calculated by logistic regression.

Results: A total of 1122 patients (aged 65.6 ± 10 years) were included in this analysis. Prostate cancer was detected in 17.8% (n = 200) of the cystoprostatectomy specimens. After multivariable adjustment, prostate cancer was significantly associated with mortality (hazard ratio 1.27, 95% confidence interval 1.03-1.56). There was a significant association between age and the presence of prostate cancer in the cystoprostatectomy specimen. The odds ratio for the presence of prostate cancer was 1.028 (95% confidence interval 1.011-1.045; P < 0.001) per each year after the age of 40 years.

Conclusions: Concomitant prostate cancer is an independent prognostic factor for mortality after radical cystoprostatectomy for bladder cancer. When considering a prostate-sparing technique, urologists should consider that every fifth to sixth patient will present with a concomitant prostate cancer, and that after the age of 40 years, the odds of a concomitant prostate cancer increases by 2.8% per year, thus warranting a careful balance between the oncological risks and quality of life issues.
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http://dx.doi.org/10.1111/iju.12073DOI Listing
September 2013

Primary chondrosarcoma of the kidney: case report and review of the literature.

Urol Int 2009 27;83(1):116-8. Epub 2009 Jul 27.

Department of Urology, University of Heidelberg Medical School, Heidelberg, Germany.

We present a case of primary renal chondrosarcoma, its diagnosis and management.
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http://dx.doi.org/10.1159/000224880DOI Listing
October 2009

Functional results 1 year after laser vaporization of the prostate: the impact of age.

J Endourol 2009 Aug;23(8):1339-42

Department of Urology, University of Heidelberg Medical School, Heidelberg, Germany.

Purpose: To test the hypothesis that age affects functional results after 80W photoselective vaporization of the prostate (PVP).

Patients And Methods: In 156 patients who were undergoing PVP for benign prostatic hyperplasia (BPH), we assessed the International Prostate Symptom Score (IPSS) and Quality of Life (QoL) score preoperatively and at 12 months. We calculated the association between age and IPSS and QoL results and corrected it for prostate-specific antigen (PSA) value, whose impact on PVP functional results is well accepted.

Results: Median patient age was 66 years (interquartile range [IQR] 62-75), median preoperative IPSS 20.5 (IQR 15-25) and QoL 4 (IQR 3-5). At 12 months, the median IPSS percent decrease was 58.8% (range 33%-75%), and the median QoL percent decrease was 66.7% (range 25%-80%). Age was independently associated with both (P < 0.05). In contrast, after adjustment for age, PSA was not significantly associated with percent IPSS decrease (P = 0.561), and its association with QoL was at the limit of significance (P = 0.05).

Conclusions: Age independently and strongly affects IPSS and QoL results at 12 months after 80W PVP.
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http://dx.doi.org/10.1089/end.2008.0649DOI Listing
August 2009

Survival in prostate cancer patients > or = 70 years after radical prostatectomy and comparison to younger patients.

World J Urol 2009 Oct 26;27(5):637-42. Epub 2009 Apr 26.

Department of Urology, University of Heidelberg, INF 110, 69120 Heidelberg, Germany.

Purpose: The purpose of our study was to evaluate and compare the survival in prostate cancer (PCa) patients who underwent radical prostatectomy (RP) < and > or = 70 years.

Methods: In a prospective cancer database, 626 patients with PCa underwent RP. Patients were categorised into two groups as follows: <70 years (n = 526, young) and > or = 70 years (n = 100, old). We evaluated the histopathological features as well as the clinical follow-up after RP. The median age was 64.4 years (41.1-80.1 years). The median follow-up was 5.3 years (0.1-15.8 years). The preoperative median prostate-specific antigen (PSA) levels for young and old patients were 8.8 ng/ml (0.4-230.0 ng/ml) and 9.9 ng/ml (0.3-165.0 ng/ml).

Results: Serum PSA levels were not different comparing the two groups (P = 0.356). The young and old patients had an organ-confined PCa in 56.3 and 58.0% (P = 0.826). They had well and moderately differentiated tumours in 78.7 and 75.0% of cases and poorly differentiated tumours in 21.3 and 25.0% (P = 0.198). Young and old patients had an ECOG > 1 in 2.3% and 7.0% of cases (P = 0.024). A 10-year PSA-free survival for young and old patients was 51.8 and 57.4% (P = 0.721), 10-year-disease-specific survival was 92.3 and 97.6% (P = 0.342), 10-year metastasis-free survival was 86.9 and 89.7% (P = 0.713), and 10-year-overall-survival was 78.1 and 71.2% (P = 0.565). Besides classical risk factors for adverse outcome on multivariate analysis, such as preoperative PSA-levels, extracapsular extension, tumour grade, and positive margin status, age was not a predictor for PSA-free- (P = 0.407), disease-specific- (P = 0.257), and overall-survival (P = 0.121).

Conclusions: In a well-selected healthy, elderly population survival outcome is not worse than that of younger patients with a follow-up of 5.3 years and curative treatment should be recommended.
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http://dx.doi.org/10.1007/s00345-009-0414-0DOI Listing
October 2009

Impact of preoperative haemoglobin concentrations on the efficiency of KTP-laser vaporization of the prostate.

World J Urol 2009 Jun 15;27(3):405-9. Epub 2009 Jan 15.

Department of Urology, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg 69120, Germany.

Purpose: The potassium-titanyl-phoshate laser (KTP laser) device produces light (wavelength of 532 nm) that is absorbed by haemoglobin, thus releasing thermal energy. This reaction causes vaporization of the tissue. We tested whether preoperative haemoglobin concentrations (Hb) affect the efficiency of the 80 W KTP laser, thus affecting the energy applied.

Methods: We assessed 164 patients undergoing KTP-laser vaporization for benign prostate hyperplasia from January 2005 to July 2006 at Heidelberg University Hospital. We prospectively collected data on patients' demographics, urodynamics, Hb, prostate volume, and energy applied. We calculated the correlation between preoperative Hb and surgery energy applied and we adjusted it for prostate volume. We further compared the postoperative urinary flow and residual volume results in non-low-Hb and in low-Hb patients.

Results: The mean age was 68.8 (+/-8.8 years), the median prostate volume 50.0 mL (interquartile range 40-80), the median preoperative urinary flow 10.1 mL/s (interquartile range 7.1-14.0), the median surgery duration 70.0 min (interquartile range 50-92.75), the median preoperative Hb 144.5 g/L (interquartile range 132-151), and the median applied energy 209.5 kJ (interquartile range 156.5-272.75). The unadjusted correlation between preoperative Hb and applied energy was -0.089 (P < 0.05). After adjustment for prostate volume this correlation was not significant (Pearson r = -0.180, P > 0.05). Functional results did not differ between low-Hb and non-low-Hb patients (P > 0.05 for urinary flow and postvoid volume).

Conclusions: Haemoglobin concentrations, in the range of clinically encountered values, do not affect the efficiency of 80 W KTP-laser vaporization of the prostate. This laser technique is thus applicable in patients with low haemoglobin concentrations without concerns about efficiency.
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http://dx.doi.org/10.1007/s00345-008-0363-zDOI Listing
June 2009

Perinephric and renal sinus fat infiltration in pT3a renal cell carcinoma: possible prognostic differences.

BJU Int 2009 May 8;103(10):1349-54. Epub 2008 Dec 8.

Department of Medical Biometry, University of Heidelberg, Heidelberg, Germany.

Objective: To evaluate the influence of perinephric (PN) and renal sinus (RS) fat infiltration on cancer-specific survival beyond other prognostic factors, as the Tumour-Node-Metastasis (TNM) classification system defines stage T3a renal cell carcinoma (RCC) as infiltration of perirenal fat and/or direct infiltration of the adrenal gland. Perirenal fat invasion is differentiated into RS and PN fat infiltration, but not further classified for the prognosis.

Patients And Methods: From 1990 to October 2007 106 patients with advanced RCC (T3a) were followed prospectively at one academic centre; all had a radical nephrectomy. To identify prognostic effects of PN, RS or RS + PN fat infiltration, univariable and multivariable Cox proportional hazard regression models were applied, including lymph node status, metastases, presence of sarcomatoid features and tumour necrosis, Fuhrman's grade, Karnofsky performance status, and tumour size.

Results: PN fat invasion alone was present in 58, RS in 21, and PN + RS in 27 patients. The median follow-up was 2.9 years; 49 patients died from RCC. In univariable and multivariable analyses RS fat infiltration was an unfavourable prognostic factor (adjusted hazard ratio, HR, 2.24, P = 0.019). Univariable analysis of RS + PN fat infiltration showed the worst prognostic effect (HR 3.25, P < 0.001). In multivariable analysis this combination was an independent prognostic factor (HR 2.75, P = 0.007), as was the presence of metastasis (HR 5.64, P < 0.001). In this group of RS + PN fat infiltration the 5-year cancer-specific survival was 31%.

Conclusion: Univariable and multivariable analyses showed that the combination of RS and PN fat infiltration is an independent unfavourable prognostic marker. We recommend that perirenal fat infiltration should be further differentiated into RS fat or PN infiltration in the TNM classification. This will better stratify patient prognosis and might allow those in need of adjuvant therapy to be identified.
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http://dx.doi.org/10.1111/j.1464-410X.2008.08236.xDOI Listing
May 2009

Is the body mass index a predictor of adverse outcome in prostate cancer after radical prostatectomy in a mid-European study population?

BJU Int 2009 Apr 24;103(7):877-82. Epub 2008 Oct 24.

Department of Urology, Medical Centre, University of Heidelberg, Heidelberg, Germany.

Objectives: To evaluate the effect of body mass index (BMI) on the histopathological and clinical outcome in prostate cancer.

Patients And Methods: In a prospective urological cancer database, 620 patients with prostate cancer had a radical prostatectomy (RP) as a curative treatment. The patients were categorized into three groups of BMI (kg/m(2)); 25.0-30.0 (343, 'overweight') and >30.0 (87, 'obese'). We evaluated the histopathological features and the clinical follow-up after RP. The median (range) age of the men was 64.4 (41.1-80.1) years and the median follow-up 5.5 (0.1-15.1) years. The preoperative median prostate-specific antigen (PSA) levels for normal, overweight and obese patients were 9.0 (0.3-133.0), 8.9 (0.4-230.0) and 9.2 (0.5-194.0) ng/mL, respectively.

Results: Serum PSA levels were no different among the three groups (P = 0.92). The normal, overweight and obese patients had organ-confined prostate cancer in 53.7%, 57.1% and 58.6%, respectively (P = 0.34) and had lymph node metastases in 7.9%, 7.6% and 4.6% (P = 0.58). Tumour grading was no different for the three groups (P = 0.25). The PSA recurrence-free, prostate cancer-specific and overall survival for the three BMI groups did not differ significantly (each P > 0.05).

Conclusion: The BMI cannot be shown to be a predictor of adverse prognosis either for histopathological features or for the clinical outcome, e.g. PSA-free, prostate cancer-specific and overall survival, in a mid-European study population after RP.
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http://dx.doi.org/10.1111/j.1464-410X.2008.08149.xDOI Listing
April 2009

High nuclear Livin expression is a favourable prognostic indicator in renal cell carcinoma.

BJU Int 2008 Dec 18;102(11):1700-6. Epub 2008 Sep 18.

Department of Urology, University of Heidelberg, Heidelberg, Germany.

Objectives: To assess the protein expression of Livin, an apoptosis inhibitor, in renal cell carcinoma (RCC) and to determine its prognostic relevance.

Patients And Methods: Immunohistochemical staining for Livin was performed in tissue microarrays (TMAs), including tumour tissue cores, from patients with RCC who had undergone renal surgery. In 682 TMAs cytoplasmatic staining intensity and nuclear staining quantity were evaluated, and the association of Livin expression with progression-free survival (PFS) and cancer-specific survival (CSS) was analysed with a multivariate Cox regression model.

Results: Over a median (range) follow-up of 5.2 (0-16.1) years, 204 patients (28%) had died from their disease. The CSS rates at 1 and 5 years for the entire cohort was 88% and 71%. Cytoplasmatic Livin staining was absent in 516 (76%) specimens; staining was positive in 166 (24%) specimens. Weak nuclear Livin staining (25%) nuclear Livin expression was a favourable independent predictor of PFS and CSS even after adjusting for tumour stage, Fuhrman grade, age, sex and Karnofsky severity rating. Cytoplasmatic Livin expression did not offer additional prognostic information.

Conclusion: High nuclear Livin expression is a favourable independent predictor of PFS and CSS in patients with RCC.
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http://dx.doi.org/10.1111/j.1464-410X.2008.07910.xDOI Listing
December 2008

Evaluation and management of a patient with a bladder mass of uncertain etiology.

Nat Clin Pract Urol 2008 Sep;5(9):509-14

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

Background: A healthy, parous, nonsmoking, 36-year-old woman consulted her gynecologist for nonspecific bladder pain. Urinary tract infection was ruled out. Vaginal ultrasonography and MRI revealed an undefined tumor between the bladder and the uterus. The patient refused further testing until tumor growth was detected at a scheduled appointment 5 months after presentation. She was referred to a urology department at this time.

Investigations: Physical examination, urine culture, medical history, cystoscopy, MRI, angiography, intraoperative frozen section analysis, and final histology.

Diagnosis: Inflammatory myofibroblastic tumor of the bladder. Management Partial cystectomy with complete excision of the tumor from the trigonal and posterior wall of the bladder by median laparotomy.
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http://dx.doi.org/10.1038/ncpuro1172DOI Listing
September 2008

The enhancer of zeste homolog 2 gene contributes to cell proliferation and apoptosis resistance in renal cell carcinoma cells.

Int J Cancer 2008 Oct;123(7):1545-50

German Cancer Research Center, Molecular Therapy of Virus-Associated Cancers (F065), Heidelberg, Germany.

The enhancer of zeste homolog 2 (EZH2) gene has been recently linked to human malignancies where it may serve as a new target for cancer therapy. Here, we analyzed EZH2 expression in primary renal cell carcinoma (RCC) specimens and in nontumorous tissue samples from adult kidney. EZH2 transcripts were detectable in all RCC specimens examined. Expression levels were significantly higher in tumor tissue (p < or = 0.0001) than in samples from normal adult kidney. Moreover, inhibition of endogenous EZH2 expression in RCC cell lines by RNA interference (RNAi) led to reduced proliferation and increased apoptosis in RCC cells. These data show that EZH2 is overexpressed in RCC. Furthermore, they indicate that the EZH2 gene plays a role for both the proliferation and the apoptosis resistance of RCC cells. Targeted inhibition of EZH2 could therefore represent a novel strategy to improve the therapeutic response of RCC.
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http://dx.doi.org/10.1002/ijc.23683DOI Listing
October 2008

Positive surgical margins after radical prostatectomy: do they have an impact on biochemical or clinical progression?

BJU Int 2008 Nov 4;102(10):1413-8. Epub 2008 Jun 4.

Department of Urology, Medical Center, University of Heidelberg, Heidelberg, Germany.

Objective: To prospectively examine the effects of the margin status after radical prostatectomy (RP), the location, and the number of positive surgical margins (PSMs) on biochemical and clinical outcome, as even if there seems to be little debate that there is a higher risk of both local and distant recurrence of prostate cancer in the face of a PSM the significance of a PSM after RP is only followed for biochemical progression in most studies.

Patients And Methods: From our prospective database, 406 consecutive well-described patients without neoadjuvant and 'direct postoperative' adjuvant therapy who underwent RP were included. The median age was 64.7 years, the median preoperative PSA level was 7.9 ng/mL, and the median follow-up was 5.2 years. We analysed pathological tumour stage, grading, number and location of PSMs, PSA-free survival, local recurrence-free survival, metastasis-free survival, prostate cancer-specific and, overall survival prospectively.

Results: The overall rate of PSMs was 17.2%. The number was higher in higher stage (P < 0.001) and higher grade tumours (P = 0.041). For a PSM the PSA recurrence rate was 64.3%, the local recurrence rate was 18.6%, the development of distant metastasis was 15.7% and therefore much higher than in patients with negative margins (20.5%, 2.7%, and 1.5%). A PSM was an adverse predictor for PSA-free survival (P < 0.001), local recurrence-free survival (P = 0.002), and development of metastasis (P = 0.003) on multivariate analysis. The number and location of PSMs was of no additional prognostic value.

Conclusions: A PSM increases the risk of biochemical and clinical e.g. local, disease progression after RP. The number and location of PSMs is of minor importance. Although only approximately 20% of patients with a PSM will develop local recurrence, surgeons should continue to strive to reduce the rate of PSMs to improve cancer control.
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http://dx.doi.org/10.1111/j.1464-410X.2008.07791.xDOI Listing
November 2008

Prognostic stratification of localized renal cell carcinoma by tumor size.

J Urol 2008 Jul 15;180(1):62-7. Epub 2008 May 15.

Department of Urology, University of Heidelberg Medical School, Heidelberg, Germany.

Purpose: Recent retrospective studies have challenged the current TNM classification of 7.0 cm to distinguish between T1 and T2 tumors. We reevaluated the optimal tumor size cutoff point that independently differentiates patient prognosis beyond the other accepted prognostic features.

Materials And Methods: From 1990 to October 2006, 398 patients who underwent radical nephrectomy for localized renal cell carcinoma (T1-T2, N0, M0) were followed prospectively. Median followup was 5.3 years and 37 patients died of tumor related causes. The optimal tumor cutoff point was calculated and multivariate Cox proportional hazards models were used to adjust for the effects of Fuhrman grade, tumor type, sex, age and Karnofsky performance status on cancer specific survival. Sensitivity analysis included all 66 patients with elective nephron sparing surgery.

Results: Univariate analysis supported 7 cm as the optimal cutoff point for prognostic stratification (p = 0.002). The 4 cm cutoff point that is used to distinguish between stage T1a and T1b could not be confirmed with analogous statistical significance (p = 0.20). On multivariate analysis tumor size dichotomized at 7 cm was an independent prognostic factor (HR 2.89, 95% CI 1.46-5.73, p = 0.002), as was Fuhrman grade 3 (HR 3.68, 95% CI 1.37-9.83, p = 0.010) and age older than 60 years (HR 3.64, 95% CI 1.63-8.14, p = 0.002). The inclusion of patients with elective nephron sparing surgery confirmed these results.

Conclusions: Univariate and multivariate analyses of our patient cohort undergoing radical nephrectomy for localized renal cell carcinoma showed no cutoff point other than 7 cm to be more suitable for distinguishing between T1 and T2 tumors, supporting the current TNM classification. In T1 tumors the analysis did not allow a clear dichotomization of tumor size in this group.
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http://dx.doi.org/10.1016/j.juro.2008.03.026DOI Listing
July 2008

Vaporization of prostates of > or =80 mL using a potassium-titanyl-phosphate laser: midterm-results and comparison with prostates of <80 mL.

BJU Int 2008 Aug 16;102(3):322-7. Epub 2008 Apr 16.

Department of Urology, Medical Center, University of Heidelberg, Germany.

Objective: To compare the safety and outcome of potassium-titanyl-phosphate (KTP) Greenlight (Laserscope, AMS, Minnetonka, MN, USA) vaporization for treating benign prostatic hyperplasia (BPH) in prostates of > or =80 vs <80 mL.

Patients And Methods: In all, 204 consecutive patients were enrolled into this prospective study; 31 were excluded from analysis for various reasons, thus 173 (median age 66.8 years; 39 with prostates of > or =80 mL) were evaluated for maximum urinary flow rate (Q(max)), postvoid residual urine (PVR), the International Prostate Symptom Score (IPSS), and quality-of-life (QoL) score. The median follow-up was 11.7 months. Of the 173 men, 26.6% were anaesthesiological high-risk patients and 32.4% took anticoagulants.

Results: The Q(max) improved in prostates of > or =80 mL from 6.9 mL/s before to 15.3 mL/s immediately after catheter removal, and 23.4 mL/s after 3 months (P < 0.001). The improvement was similar to that in smaller prostates. There were equally effective changes in PVR (P < 0.001). The IPSS decreased from 19.0 before to 7.0, 4.0 and 5.5 at 3, 6 and 12 months after surgery (P < 0.001). Changes did not differ from those in smaller glands. The results were similar for QoL (P < 0.001). During surgery there was no major bleeding and no transurethral resection syndrome. There was acute urinary retention after catheter removal in 10.4% of men; 4.6% developed urinary tract infections, whereas the rate was higher in men with larger prostates (10.3%). The re-operation rate was higher in men with larger prostates, at 23.1% vs 10.4% (P = 0.09). CONCLUSION KTP laser vaporization is a safe and effective procedure for surgically treating BPH. The functional outcome in larger prostates is similar to that in smaller glands, but there was a serious trend to a higher re-operation rate in men with larger prostates.
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http://dx.doi.org/10.1111/j.1464-410X.2008.07563.xDOI Listing
August 2008

Change of ureteral submucosal anti-reflux implantation into an intussuscepted ileal nipple valve as reflux protection in ureterosigmoidostomy.

Urology 2008 Jul 14;72(1):192-5. Epub 2008 Apr 14.

Department of Urology, University of Heidelberg, Heidelberg, Germany.

Objectives: After submucosal implantation of the ureters in ureterosigmoidostomy failed for different reasons, urologists are confronted with the task of creating a new form of urinary diversion. Therefore, the implantation site of the ureters must be removed because of the risk of secondary malignancy with the consequences of a large colonic defect.

Technical Considerations: Here we describe a technique for reimplantation of both ureters with an intussuscepted ileal nipple in ureterosigmoidostomy with three advantages for the patient in situations in which classical submucosal implantation failed after several years. We were able to avoid conversion into another form of incontinent or continent urinary diversion. To prevent the development of colonic tumors at the implantation site where urothelial meets colonic epithelium, we interposed an ileal segment which avoids this epithelial contact. We were also able to cover a large colonic defect which was mandatory to receive a negative surgical margin when the tumor was resected.

Conclusions: This technique of using an ileal nipple as reflux protection in ureterosigmoidostomy allows the patient to keep the form of urinary diversion he is used to live with, for many decades.
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http://dx.doi.org/10.1016/j.urology.2008.01.071DOI Listing
July 2008

The influence of body mass index on the long-term survival of patients with renal cell carcinoma after tumour nephrectomy.

BJU Int 2008 May 5;101(10):1243-6. Epub 2008 Feb 5.

Department of Urology, University of Heidelberg, Germany.

Objective: To assess whether under- or overweight at the time of surgery has any effect on the survival of the patients with renal cell carcinoma (RCC), as obesity increases the risk of developing RCC.

Patients And Methods: We prospectively evaluated 780 patients who had nephrectomy for RCC between 1990 and 2005. We used uni- and multivariate Cox proportional hazards models to assess the effect of body mass index (BMI), tumour stage, Fuhrman grade, age, sex, histological type and performance status on cancer-specific survival (CSS). Patients were grouped according to BMI (in kg/m(2)), as underweight (<18.5), normal (18.5-<25), overweight (25-<30) and obese (>or=30).

Results: The median (range) follow-up was 5.3 (0.5-15.4) years, the patients being followed until June 2006; 254 patients died during the follow-up. Multivariate analyses of all patients showed that tumour stage, Fuhrman grade, Karnofsky performance status, age, sex and BMI were independent prognostic factors for CSS. While underweight patients had a significantly worse prognosis than those of normal weight, overweight or obese patients had a similar outcome to that of patients of normal weight. In a subgroup analyses including patients with localized RCC only, there was a strong tendency to less aggressive disease in the overweight group (P = 0.081).

Conclusions: Being underweight is an unfavourable and new risk factor for CSS in patients with RCC treated by nephrectomy. Although not significant, there seems to be a limited favourable prognostic effect of overweight on CSS in patients with localized RCC.
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http://dx.doi.org/10.1111/j.1464-410X.2007.07375.xDOI Listing
May 2008

En bloc stapler ligation of the renal vascular pedicle during laparoscopic nephrectomy.

BJU Int 2008 Apr 5;101(7):878-82. Epub 2007 Dec 5.

Department of Urology and Paediatric Urology, University of Heidelberg, Medical School, Germany.

Objectives: To evaluate, in a prospective series of laparoscopic nephrectomies (LNs), the safety and feasibility of en bloc stapling for resection and occlusion of the vascular renal pedicle.

Patients And Methods: Between October 2003 and March 2006, we investigated the intra- and postoperative outcomes in patients undergoing planned en bloc stapling of the renal vein and artery during LN. We also assessed complications at 6 and 12 months.

Results: In all, 57 patients, with a mean (range) age of 59.8 (10-83) years, were enrolled. The indications for LN were: renal cell carcinoma (RCC) in different stages in 66.7%, transitional cell carcinoma in 3.5% and oncocytoma in 5.2%. In a further 19.2% the patients presented with nontumoral lesions and the remaining 5.4% consisted of several rarer entities. The mean (sd) tumour size was 4.7 (1.75) cm. In one case (1.8%) a conversion to open nephrectomy was necessary because of a stapling device failure. Three patients (5.4%) underwent revision for bleeding. The median (range) blood loss was 100 (50-1000) mL. The median operating duration was 145 (95-410) min; in 19.3% this included additional surgical or diagnostic procedures. At 6 and 12 months after LN, there were no complications related to the surgical technique, in particular there was no arterio-venous fistula.

Conclusions: We conclude that in our prospective series, en bloc stapling of the renal vascular pedicle during LN was a safe technique and that it was feasible in a time at the lower limit of the range of reported durations for similar procedures.
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http://dx.doi.org/10.1111/j.1464-410X.2007.07371.xDOI Listing
April 2008

Thoraco-abdominal approach to large retroperitoneal tumours.

BJU Int 2006 Nov 28;98(5):969-72. Epub 2006 Jul 28.

Department of Urology, University of Heidelberg, Germany.

Objectives: To evaluate the thoraco-abdominal approach for resection of retroperitoneal tumours, as this approach is rarely used because, although exposure is excellent, morbidity is presumed to be increased.

Patients And Methods: From October 2003 to September 2005, 21 patients (six female, 15 male), aged 14-76 years, underwent resection of very large and/or T4 retroperitoneal tumours through a thoraco-abdominal approach.

Results: In 16 (76%) patients tumour resection was complete. There were no significant complications during surgery. After surgery, there were complications in six patients (29%), in four of whom there was no long-term impairment. One patient died at 75 days after surgery from a complicated retroperitoneal haematoma. The mean (range) estimated blood loss was 2883 (50-20 000) mL, the intensive-care unit stay was 3.85 (0-30) days and the intermediate-care unit stay 2.6 (0-9) days. With a mean follow-up of 9.6 (1-19) months, 15 patients (72%) are recurrence-free, two (10%) have progressive disease, and four (19%) have died from malignancy.

Conclusions: The thoraco-abdominal approach permits excellent exposure of the retroperitoneum for large and/or T4 tumours, allowing radical surgery in cases considered otherwise inoperable. Additional advantages are the possibilities of early vascular control and easy surgical extension of the procedure. These facts, combined with the reasonable morbidity found in our series, support the integration of the thoraco-abdominal approach in the regular options for urological surgery.
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http://dx.doi.org/10.1111/j.1464-410X.2006.06418.xDOI Listing
November 2006