Intraoperative radiation therapy (IORT) is a radiation technique applying a single fraction with a high dose during surgery. We report the first abdomino-pelvic application of an image-guided intraoperative electron radiation therapy with intraoperative real time dose calculation based on the individual intraoperative patient anatomy. A patient suffering from locoregionally recurrent rectal cancer after treatment with neoadjuvant re-chemoradiation was chosen for this approach. After surgical removal of the recurrence, an adequate IORT applicator was placed as usual. A novel mobile imaging device (ImagingRing, MedPhoton) was positioned around the patient covering the region to be treated with the IORT-applicator in place. It allowed the acquisition of three-dimensional intraoperative cone-beam computed tomography images suitable for dose calculation using an automated scaling (heuristic object and head scatter as well as hardening corrections) of Hounsfield units. After image acquisition confirmed the correct applicator position, the images were transferred to our treatment planning system for intraoperative dose calculation. Treatment could be accomplished using the calculated dose distribution. We herein describe the details of the procedure including necessary adjustments in the typically used IORT equipment and work flow. We further discuss the pros and cons of this new approach generally overcoming a decade long limitation of IORT procedures as well as future perspectives regarding IORT treatments.

Abstract Purpose: To compare oncological, peri-, and postoperative outcomes of robot-assisted with those of laparoscopic partial nephrectomy. Patients and Methods: Thirty patients with low- or moderate-complexity renal tumors (R.E.N.A.L. nephrometry scoring) were randomized in a single-blind manner and operated on by the robot-assisted (n = 13) or laparoscopic (n = 17) approach. The primary outcome was oncological safety, based on the residual tumor (R) classification. Secondary outcome parameters were perioperative and postoperative results. The open-source R statistical software was used for statistical analysis. Results: Oncological outcomes did not differ significantly between the two surgical methods (p = 0.58). Operating time (p = 0.105), ischemia time (p = 0.884), overall length of hospital stay (p = 0.664), postoperative pain, and preoperative and in-hospital renal function scores were similar. Creatinine levels differed significantly six months postoperatively (robotic: 0.9 mg/dl versus laparoscopic: 1.1 mg/dl; p= 0.014). Intraoperative blood loss was significantly greater in the laparoscopic group (400 ml versus 168 ml; p = 0.028), which was also reflected in postoperative hemoglobin levels (13.8 mg/dl versus 12.5 mg/dl; p = 0.012). Peri- or postoperative complications did not differ significantly (p = 0.355). Subgroup analysis revealed significantly more frequent complications in patients with moderate-complexity tumors treated by laparoscopic surgery (p = 0.021). Conclusions: The oncological outcome in regard to the R status was similar in both groups. Intraoperative blood loss, postoperative renal function, and complications all benefited from robot-assisted surgery. Trial registration: The study was registered on ClinicalTrials.gov (NCT03900364; 03/04/2019).

Zusammenfassung Ziel Wir verglichen in unserer retrospektiven Multicenterstudie die Ergebnisse der konventionell laparoskopischen Nierenbeckenplastik (L-NBP) mit denen der roboterassistierten Nierenbeckenplastik (R-NBP) nach Einführung des da Vinci X-Systems. Methoden Insgesamt wurden im definierten Zeitraum von Mai 2015 bis September 2019 76 Nierenbeckenplastiken an zwei unterschiedlichen Universitätskliniken durchgeführt. Für die Datenanalyse wurden 63 Patienten berücksichtigt, welche entweder eine L‑NBP ( n = 27) oder eine R‑NBP ( n = 36) nach Anderson und Hynse erhielten. Ergebnisse Das mediane Follow-up lag bei 22,5 (L-NBP) bzw. 12,7 (R-NBP) Monaten. Die statistische Analyse der Patientengruppen ergab bzgl. Alter, BMI, Geschlecht und betroffener Seite keinen statistischen Unterschied. Die Operationszeit war in der Gruppe der R‑NBP nicht statistisch signifikant kürzer (180 ± 72 vs. 159 ± 54 min, p = 0,194). Bezüglich postoperativer Major- bzw. Minor-Komplikationen nach Clavien-Dindo, Krankenhausaufenthaltsdauern (7,48 ± 2,86 vs. 6,33 ± 2,04 Tage) und Erfolgsrate ergab sich ebenso kein statistisch signifikanter Unterschied. Schlussfolgerung Unsere Daten zeigen keinen signifikanten Unterschied der beiden Gruppen bezogen auf die peri- und postoperativen Ergebnisse. Es konnte gezeigt werden, dass für den Patienten auch unmittelbar nach Implementierung eines robotischen Systems kein Nachteil entsteht.

To investigate the role of en bloc re-resection (EBRS) in patients who had undergone previous en bloc resection for high-risk non-muscle-invasive bladder cancer (NMIBC). An international, multicenter, observational retrospective analysis of prospectively collected data. Patients with a high-risk NMIBC who had previously undergone en bloc resection were scheduled for EBRS of the resected area after 40 days. The primary outcome was the presence of residual tumor or recurrence-free survival. Overall, 78 patients underwent EBRS. Only five (6.41%) residual cancers were found: one patient had a pTa G3 (1.28%) cancer and four (5.13%) had a pTis. The detrusor muscle was preserved in all samples. Only one patient had a positive margin on EBRS. No procedure called for a conversion to traditional re-TURBT. No patient experienced bladder perforation or other intra-operative complications. The recurrence rate at the first follow-up cystoscopy (RRFF-C at 3 months) was 3.85% (three patients). The median follow-up period was 30.8 months (range 6.9–76.0 months). In univariate analysis, the only predictor of recurrence was grade. Overall we observed 11 recurrences. Only one tumor progressed to T2 MIBC. The low rates of residual tumor, recurrence, and progression seem to raise doubts about the efficacy of EBRS in patients who have previously undergone en bloc resection. EBRS appears to be a feasible and safe procedure with a low rate of complications. However, further data will be needed before EBRS can be used in clinical trials or recommended as a treatment modality.

Background Over the last few years the number of flexible ureterorenoscopies, used for renal stone treatment, has risen steadily. This was associated with an increase in costs for maintenance and repair of the fragile ureterorenoscopes used. To overcome this problem single-use devices have been introduced to the market. The aim of this study was to assess surgical outcome and workability for LithoVue™, a single-use flexible ureterorenoscope. Methods We retrospectively analyzed all flexible ureterorenoscopies performed at our department between January and October 2017. We included a total of 108 interventions for renal stone therapy, all performed using the single-use device LithoVue™. We assessed patients’ characteristics including stone size, count and location. We evaluated the surgical outcome, analyzing stone-free rates, reintervention rates, complication rates, as well as surgery time. Learning curve for single-use ureterorenoscopes was evaluated by comparing the surgical outcome between residents and consultants. Results The average time needed per intervention was 52,31 min ± 28,11. In 77 out of 108 (71,30%) patients we were able to remove all stones by a single intervention. In 8 patients (7,41%) intra- or postoperative complications occurred, none of which was graded higher than Clavien-Dindo III B. We did not find any statistical differences comparing the surgical outcome between residents and consultants. No technical difficulties occurred during surgery. Conclusion Single-use flexible ureterorenoscopes provide decent working properties resulting in good surgical outcome. Furthermore, they are proven to be easy to handle even for unexperienced surgeons, making them a feasible choice for high volume academic centers.

Background: Postmicturition dribble (PMD) is a common condition in the male population. Objectives: Despite its common occurrence, there are only a few studies on this topic so far. The aim of this study was to investigate possible physiological aspects of PMD. Method: Seventeen men complaining of PMD and 10 healthy subjects were assessed via uroflometry, IPSS questionnaire, IIEF-5 questionnaire, and an adapted visual analogue scale (VAS) for ejaculation force -(0-10) and the amount of bother concerning PMD (0-10) were completed. In addition to that, a retrograde urethrography at 40 and 60 cm water column as pressure unit to measure the width of the bulbar urethra was performed, and the amount of PMD was measured with an adjusted pad test. Results: The PMD group showed a significantly worse IPSS score, a lower Qmax rate in uroflowmetry, a worse IIEF-5 score, and a worse VAS score concerning ejaculation force. In both groups, worse IPSS levels correlated with a low bulbar urethral diameter at 40 and 60 cm water column. Another correlation was found between a high maximum urine flow rate and a larger bulbar urethral diameter at 40 and 60 cm. Both groups showed urine loss after micturition, with no bother (VAS 0) in the control group, whereas the PMD group showed a VAS of 6. Conclusions: PMD should be regarded as a physiological occurrence in men rather than a disease by itself. Suffering is only to be expected in combination with other lower urinary tract symptoms. (c) 2019 S. Karger AG, Basel

Complete removal of the adrenal gland has been the standard approach in the surgical treatment of tumors for decades. There, however, is bigger role emerging for organ sparing adrenalectomy especially in the era of minimal invasive surgery. Initially proposed for bilateral tumors in hereditary diseases and in tumors in a solitary gland, partial adrenalectomy gained also popularity in the treatment of spontaneous unilateral small masses. Various surgical techniques have been described so far with promising surgical and functional outcomes with increased quality of life compared to total adrenalectomy. Steroid replacement can be avoided in most cases even in bilateral disease and successful normalization of pathological preoperative endocrine levels were reported in various kinds of adenoma. Therefore, minimal invasive partial adrenalectomy, which seems to be still underused, is a valid treatment option for small hormonal active adrenal tumors whenever surgically possible.

In renal tumors, suspicious for renal cell carcinoma, where there is any doubt and discrepancy between morphology and immune profile, we recommend performing further immunohistochemical staining for pan-cytokeratin, S100, NSE, and inhibin-alpha. Thus, follow-up overtreatment can be avoided in cases of benign kidney tumors.

Purpose Warm ischemia (WI) and bleeding constitute the main challenges for surgeons during laparoscopic partial nephrectomy (LPN). Current literature on the use of lasers for cutting and coagulation remains scarce and with small cohorts. We present the largest case series to date of non-ischemic LPN using a diode laser for small exophytic renal tumors. Methods We retrospectively evaluated 29 patients with clinically localized exophytic renal tumors who underwent non-ischemic laser–assisted LPN with a 1318-nm wavelength diode laser. We started applying the laser 5 mm beyond the visible tumor margin, 5 mm away from the tissue in a non-contact fashion for coagulation and in direct contact with the parenchymal tissue for cutting. Results The renal vessels were not clamped, resulting in a WIT (warm ischaemic time) of 0 min, except for one case that required warm ischemia for 12 min and parenchymal sutures. No transfusion was needed, with a mean Hemoglobin drop of 1,4 mg/dl and no postoperative complications. The eGFR did not significantly change by 6 months. Histologically, the majority of lesions ( n = 22/29) were renal-cell carcinoma stage pT1a. The majority of malignant lesions ( n = 13/22) had a negative margin. However, margin interpretation was difficult in 9 cases due to charring of the tumor base. A mean follow-up of 1.8 years revealed no tumor recurrence. The mean tumor diameter was 19.4 mm. Conclusion The 1318-nm diode laser has the advantages of excellent cutting and sealing properties when applied to small vessels in the renal parenchyma, reducing the need for parenchymal sutures. However, excessive smoke, charring of the surgical margin, and inability to seal large blood vessels are encountered with this technique.

Wir präsentieren einen Fall eines 57-jährigen Patienten mit intermittierenden Hb(Hämoglobin)-wirksamen Blutungen aus der Harnröhre nach traumatischer Katheteranlage. Ursächlich für die Blutung war ein arterielles Pseudoaneurysma in der bulbären Harnröhre. Die Blutungsquelle konnte mittels Angiographie dargestellt und embolisiert werden.

Zusammenfassung Hintergrund Die adjuvante intravesikale Instillation von Bacillus Calmette-Guérin (BCG) stellt bei Patienten mit nicht-muskelinvasivem Harnblasenkarzinom (NMIBC) mit hohem Risiko die Therapie der ersten Wahl dar. Nichtsdestotrotz entwickeln etwa 40 – 50 % dieser Patienten trotz Therapie ein Rezidiv oder eine Progression. Die radikale Cystektomie (RC) stellt für diese sogenannten BCG-Versager die Therapie der ersten Wahl dar. Da jedoch nicht alle Patienten für eine RC geeignet sind oder diese ablehnen, gibt es einen Bedarf an konservativen Therapiealternativen. Ziel dieser Studie war die Erhebung von konservativen Therapieoptionen für Patienten mit NMIBC nach BCG-Versagen. Material und Methoden Es erfolgte eine systematische Recherche in folgenden Literaturdatenbanken: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE und EMBASE. Dabei wurden alle randomisierten kontrollierten Studien (RCTs), quasi RCTs und single-Arm Studien von Patienten mit BCG-Versagen und einer Mindest-Patientenzahl von acht, die einer intravesikalen oder systemischen Therapie unterzogen wurden, eingeschlossen. Es wurden nur Publikationen in englischer Sprache berücksichtigt. Die Literaturrecherche und Datenanalyse erfolgte durch zwei Gutachter. Folgende Kriterien wurden erhoben: vollständiges Therapieansprechen (CR), Rezidiv, rezidivfreies Überleben (RFS), Krankheitsprogression und Rate an RC. Ergebnisse 42 Publikationen mit einer Gesamtzahl von 3521 Patienten (davon 2371 BCG-Versager) wurden in die systematische Übersichtsarbeit eingeschlossen. Als konservative Therapieoptionen wurden Valrubicin, Taxane, Gemcitabin, Chemotherapie-Kombinationen, Thermochemotherapie, Photodynamische Therapie, Kombinationstherapie aus BCG und Interferon, zielgerichtete Therapien (targeted therapies) und Immuntherapien identifiziert. Die höchste klinische Evidenz konnte für Taxane, Gemcitabin und die Thermochemotherapie bei gleichzeitig geringer Toxizität festgestellt werden. Schlussfolgerung Trotz teilweise guter Ansprechraten mit Taxanen, Gemcitabin und der Thermochemotherapie kann für Patienten mit BCG-Versagen keine Evidenz-basierte konservative Therapieoption empfohlen werden, die der RC überlegen ist. BCG-Versager stellen eine heterogene Patientengruppe dar. Der Begriff „BCG-Versagen“ wird in der Literatur uneinheitlich verwendet. Zur Identifikation von konservativen Therapieoptionen bei BCG-Versagern sind prospektiven Studien mit homogenem Design von großer Bedeutung.

Background Adjuvant Bacillus Calmette-Guerin (BCG) intravesical instillation is the recommended standard treatment in patients with high-risk non-muscle-invasive bladder cancer (NMIBC). However, a significant proportion of patients fail treatment, and radical cystectomy (RC) is the subsequent gold standard. On the other hand, there is an unmet need for conservative alternatives for patients who are unfit or unwilling to undergo surgery. This study aimed to identify conservative treatment options in NMIBC patients after BCG failure. Material and Methods We performed a systematic search in the databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, including all randomised controlled trials (RCTs), quasi-RCTs and singlearm studies, in which patients with NMIBC were treated with second-line intravesical or systemic therapy after BCG failure. A minimum of eight patients were included in each treatment arm. Full papers were restricted to English language. Literature research and data analysis were assessed independently by two reviewers. Data on treatment response, recurrence, time to recurrence, progression and rate of cystectomy were collected and analysed. Results This systematic review included 42 publications with a total of 3521 patients (2371 BCG failures). Valrubicin, taxanes, gemcitabine, combination chemotherapy, thermochemotherapy, photodynamic therapy, combination of BCG and interferon and immunotherapies or targeted therapies were identified as conservative treatment options. For taxanes, gemcitabine and thermochemotherapy there is the highest evidence for a clinical meaningful response with minor toxicities. Conclusions Despite some promising response rates for taxanes, gemcitabine or thermochemotherapy, an evidence-based recommendation for treatment options superior to RC in patients failing BCG therapy cannot be made. The definition of BCG failure is still inconsistent and heterogeneous outcomes in patients with BCG failure have been reported. In order to identify effective conservative therapy options in patients failing BCG therapy, prospective trials with a standardised trial design are needed.

OBJECTIVES To demonstrate the feasibility of our novel natural orifice transluminal endoscopic surgery (NOTES)-assisted approach with medium-term follow-up. PATIENTS AND METHODS From March 2012, we included all patients who presented to our clinic with symptomatic or complicated retentive bladder diverticula secondary to long-standing infravesical obstruction. After managing the primary cause, we proceeded in all cases to our novel NOTES-assisted approach. We followed up the patients with abdominal ultrasonography at 6 weeks and 12 months postoperatively. Success was determined as subjective relief of the symptoms and objective disappearance of the diverticula in postoperative retrograde cystogram (RGC). RESULTS Between March 2012 and August 2014, eight diverticula were treated using our new technique. The surgery was uneventful. The mean operative time was 134.25 ± 44.92 minutes. Blood loss was minimal (>50 mL). Retrograde cystography was performed on the 10th postoperative day. The introduction of the needle holder through the urethral natural orifice (NOTES) facilitated a more optimal direction of the needle holder for suturing the bladder wall due to its parallel position in relation to the trigone and posterolateral walls. This renders this step easier compared with suturing the bladder wall through the transvesical laparoscopic ports. One case had a grade IIIa complication according to the Clavien-Dindo classification of surgical complications. The study is limited by the small number of cases. CONCLUSION Laparoscopic transvesical bladder diverticulectomy is a promising and safe procedure with good outcomes. Using the urethra (NOTES assisted) as an extra access to the bladder facilitates diverticular traction and bladder suturing without the need for extra ports. This technique can also be applied together with the novel T-laparoendoscopic single-site surgery approach.

4520 Background: There are no established serum markers to monitor UC progression, response to therapy and to evaluate the risk for metastases. This study was set up to define the percentage of CTC positive UC pts at progression after platinum based combination therapy, potential CTC cut-off levels for drug screening and the HER2 status on CTC in comparison to the primary tumor. Methods: Blood samples from pts who fulfilled the inclusion criteria were analysed with CellSearch- CTC Kit and -Tumor Phenotyping Reagent HER2/neu. Results were reported as number of CTC/7.5 mL whole blood. Paraffin embedded tumor tissue was evaluated for HER2 positivity (FISH) and compared to that on CTC. The correlation between CTC parameters, the HER2 status of the primary tumor, and the Bellmunt prognostic groups (0-3) were investigated using descriptive statistics. The planned sample size of 70 pts should allow for a two-sided 95% confidence interval with a width of +/- 12% for the expected rate of 50% CTC positive pts. Results: 70 pts with platinum refractory UC were enrolled in 8 institutions and 69 pts fulfilled all inclusion criteria and CTC of 63 pts were evaluable. 66/69 pts had measurable metastases (38 visceral metastases of which 23 were in the liver). 21, 29, 14 and 5 pts belonged to Bellmunt prognostic groups 0,1,2,3, respectively. In 42 of 63 evaluable pts (66%) CTC (≥ 1 CTC) were detectable, and 29 (46.0%), 25 (39.7%) and 23 (36.5%) pts had more than 2, 3 and 5 CTC/7.5ml, respectively. In 3 pts HER2-positive CTC were detected; HER2 gene amplification on the primary tumor was found in 6/46 cases (13%). All patients with HER2-positive primary tumors also harboured CTC. HER2-positive CTC were found in 2 pts with HER2 amplified primary tumors and in one patient with a HER2-negative primary tumor. In 3/5 pts with HER2 amplified tumors CTC were HER2 negative. HER2 positive CTC were significantly correlated with the Bellmunt risk group 3 (60%, CI 23.1- 88.2) but not with the HER2 status of the primary tumor. Conclusions: CTC are present in a considerable number of platinum refractory UC patients and might serve as a drug screening biomarker as well as for the detection of targetable molecular alterations. Clinical trial information: EudraCT 2013-000124-34.

Neoadjuvant chemotherapy before radical cystectomy is recommended in patients with bladder cancer in clinical stages T2-T4a, cN0M0. We analyzed the frequency and current practice of neoadjuvant chemotherapy in 679 patients using uni- and multivariable regression analyses and using a questionnaire. We found a great discrepancy between guideline recommendations and practice patterns, despite medical indication and interdisciplinary tumor board discussion.Introduction: Guidelines recommend neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) in patients with urothelial carcinoma of the bladder in clinical stages T2-T4a, cN0M0. We examined the frequency and current practice of NAC and sought to identify predictors for the use of NAC in a prospective contemporary cohort. Materials and Methods: We analyzed prospective data from 679 patients in the PROMETRICS (PROspective MulticEnTer Radical Cystectomy Series 2011) database. All patients underwent RC in 2011. Uni- and multivariable regression analyses identified predictors of NAC application. Furthermore, a questionnaire was used to evaluate the practice patterns of NAC at the PROMETRICS centers. Results: A total of 235 patients (35%) were included in the analysis. Only 15 patients (2.2%) received NAC before RC. Younger age (< 70 years; P = .035), lower case volume of the center (< 30 RC/year; P < .001), and advanced tumor stage (>= cT3; P = .038) were identified as predictors for NAC. Of the 200 urologists who replied to the questionnaire, 69% (n = 125) declared tumor stage cT3-4 a/o N1M0 to be the best indication for NAC application, although 45% of the urologists stated that they would not perform NAC despite recommendations. The decision for NAC was made by the individual urologist in 69% of cases, and only 29% reported that all cases were discussed in an interdisciplinary tumor board. Conclusion: NAC was rarely applied in the present cohort. We observed a discrepancy between guideline recommendations and practice patterns, despite medical indication and pre-therapeutic interdisciplinary discussion. The potential benefit of NAC within a multimodal approach seems to be neglected by many urologists. (C) 2016 Elsevier Inc. All rights reserved.

Im Rahmen der Abklärung eines 71- jährigen Patientens mit therapierefraktärer Hypertonie auf sekundäre Formen wurde eine extraadrenale Raumforderung gefunden. Nach weiterführender Bildgebung und biochemischer Abklärung wurde ein extraadrenales Phäochromozytom diagnostiziert, welches nach Alpha-Rezeptorblockade über einen posterioren Zugang laparoskopisch entfernt werden konnte. Das Phäochromozytom ist mit einer Inzidenz von 1–2 von 100.000 ein seltener katecholamin-produzierender Tumor. In etwa 1–25 % ist er extraadrenal lokalisiert. Zur Diagnosesicherung sollten die Hormonaktivität mittels Katecholaminbestimmung im Harn bzw. Plasma sowie eine Bildgebung erfolgen. Nach Blockade mit einem Alpha-Blocker stellt die komplette chirurgische Resektion die Therapie der Wahl dar.