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

Ziele: Minimalinvasive Therapieoptionen gewinnen zunehmend an Bedeutung bei der Behandlung von Nierenraumforderungen unklarer Ätiologie. Ziel dieser Studie ist die Evaluation des kurz- und mittelfristigen Verlaufs einer Radiofrequenzablation von Nierenzellkarzinomen bis 5cm Größe. Methode: 19 Patienten mit einem Durchschnittsalter von 69,7 Jahren wurden von der urologischen Klinik zur Radiofrequenzablation von Nierenzellkarzinomen überwiesen. Bei allen Patienten wurde die Diagnose entweder histologisch, durch mehrere bildgebende Verfahren oder den klinischen Verlauf gesichert. Die durchschnittliche Größe der Raumforderungen vor Ablation betrug 2,6cm. Alle Ablationen erfolgten unter computertomographischer Durchleuchtungskontrolle an einem Multislicecomputertomographen (Aquilion 64, Fa. Toshiba). Zur Anwendung kamen Ein- und Dreifachsonden der Fa. Radionics (Burlington, USA). Bei 17 Patienten erfolgte die Ablation eines singulären Herds, bei zwei Patienten wurden zwei Raumforderungen abladiert. Der Zugangsweg erfolgte in 18 von 19 Fällen lateral oder dorsal, bei einem Patienten ventral. Die Ablationstemperatur betrug im Durchschnitt 83°C bei einer Applikationsdauer von durchschnittlich elf Minuten. Die Größe des Ablationsareals in der unmittelbaren Bildkontrolle betrug im Durchschnitt 3,0cm. Die erste Kontrolluntersuchung erfolgte unmittelbar nach Ende der RFA, die zweite frühestens nach 3 Monaten. Ergebnis: Bei allen Patienten zeigte sich in der unmittelbar postinterventionellen, kontrastmittelgestützten Computertomographie eine Minderperfusion des gesamten Nierenzellkarzinoms. Komplikationen wie Blutungen, Organperforationen oder thermische Verletzung traten nicht auf. In den nach durchschnittlich 10 Monaten durchgeführten Kontrolluntersuchungen konnte kein Lokalrezidiv in den abladierten Arealen nachgewiesen werden. Die Patienten konnten ausnahmslos zwei Tage nach der Intervention die Klinik in Wohlbefinden verlassen. Metastasen entlang des Zugangsweges traten nicht auf. Schlussfolgerung: Die kurz- und mittelfristigen Verlaufkontrollen lassen die RFA als onkologisch vertretbare Therapieoption im Vergleich zur chirurgischen Resektion erscheinen. Die perkutane Radiofrequenzablation darf als Alternative bei Tumoren bis 5cm Größe betrachtet werden, wenn Kontraindikationen gegen eine chirurgische Resektion bestehen.

Terminal niereninsuffiziente Patienten bedürfen bis zur Nierentransplantation (NTX) einer regelmäßigen urologischen Vorsorgeuntersuchung. Ziel ist die Früherkennung und Behandlung urologischer Tumoren, die Abklärung der oberen und unteren Harnwege und ggf. die Indikationsstellung zu einer urologischen Operation vor Freigabe zur NTX (z. B. Nephrektomie bei polyzystischen Nieren). Die urologische Nachbetreuung nierentransplantierter Patienten dient vornähmlich der Erkennung und Behandlung von Harnleiterkomplikationen und symptomatischen Lymphozelen. In der längerfristigen Nachsorge liegt das Augenmerk auf der Tumorfrüherkennung. Die Behandlung einer eventuellen erektilen Dysfunktion nach Nierentransplantation gehört ebenfalls zu den Aufgaben des behandelnden Urologen.

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

Patients with end-stage renal disease awaiting kidney transplantation require regular urological evaluation. The urologist's main task is early diagnosis and treatment of genitourinary malignancies and evaluation of the lower urinary tract. Furthermore, urologists are often confronted with the question of whether or not to perform pretransplant urological surgery, i.e., native nephrectomy for polycystic kidney disease. Urological care after kidney transplantation involves diagnosis and treatment of ureteral complications, malignancies, lower urinary tract symptoms, and last but not least erectile dysfunction, which has a prevalence of 20-50% among kidney transplant recipients.For the evaluation and follow-up of the living kidney donor, international guidelines have been developed in recent years to also help the urologist to perform a correct evaluation and follow-up of the kidney donor.

Die laparoskopische Lebendspendernephrektomie (LDN) wurde vor 10 Jahren erstmals durchgeführt. Heute wird sie in vielen amerikanischen Zentren routinemäßig praktiziert. In der vorliegenden Arbeit werden die verschiedenen Aspekte der LDN, deren Auswirkungen für Spender, Organ, Empfänger und Operateur evaluiert. Es folgt die Literaturrecherche und -vergleich zum Thema laparoskopische Donornephrektomie und zu den verschiedenen Teilaspekten werden die Besonderheiten dieser Methoden und die eigenen Erfahrungen am aktuell größten deutschen LDN-Zentrum Zentrum (Charité Berlin, Campus Mitte) dargestellt.

INTRODUCTION:Laparoscopic living donor nephrectomy (LDN) offers multiple advantages to the donor. Since 1999 LDN has become the only surgical approach for living kidney donation in our department. To our knowledge a donor health-related quality of life (QoL) has not yet been performed with standardized and validated questionnaires to compare laparoscopic with open nephrectomy. We therefore performed a study with two questionnaires (SF-36/GBB-24) and one set of open questions for all donors in our department. METHODS:Questionnaires were sent out to all donors between 1983 and 2001 with at least a 1-year follow-up. To exclude a bias a maximum response rate was sought; donors who did not answer were recontacted as well as their recipients or their physicians to motivate them for participation. RESULTS:The response rate was (89.8%). Except for less limb pain in the laparoscopy group, no difference could be detected for donors QoL with respect to the surgical method. Willingness to donate again was not affected by the surgical method. Nevertheless if asked again today, most donors want laparoscopic kidney retrieval. CONCLUSIONS:Donors health-related QoL is not affected by the surgical method when queried retrospectively. Nevertheless, most donors today would favor laparoscopy, if they could chose again. How laparoscopy affects a reluctant donor to step forward must be determined in a prospective study.

OBJECTIVES:With increasing surgical skills and novel methods of hemostasis laparoscopic Partial nephrectomy has become an attractive treatment option for selected renal tumors. We report techniques, perioperative data and oncological outcome in a single center experience with three different surgeons. PATIENTS AND METHODS:Between March 2001 and October 2004, 44 patients underwent laparoscopic transperitoneal partial nephrectomy for exophytic tumors. Median tumor size was 3 cm (1-5 cm). In 25 cases the renal artery was clamped using endoscopic bulldog clamps and tumor resection was performed with scissors or the harmonic scalpel. Hemostasis was achieved by application of FloSeal only; closure of the collecting system with Lahodny sutures was performed, if necessary. Frozen sections were obtained in all cases. RESULTS:All procedures were successful with no intraoperative complications. Mean surgical time was 210 min (115-355 min); clamping time was 21 min (7-41 min) in 25 cases. In 8 cases suturing of the collecting system was required. Margins were negative in 37 cases, in five cases secondary resection was necessary to achieve negative margin status; in two cases radical nephrectomy was performed. There were no significant differences between surgeons in terms of patient data and results. At a mean follow-up of 15 months (6-37 months) no recurrence was observed. CONCLUSIONS:Laparoscopic partial nephrectomy using FloSeal is a feasible and safe method for treatment of small renal masses. The technique is reproducible by surgeons who are used to complex laparoscopic procedures like expected in high volume laparoscopic centers.

Objectives: Renal cell carcinoma is likely to become one of the most important indication for laparoscopic surgery. The laparoscopic technique combines the benefits of minimal invasive approach with established surgical principles. In our institution the laparoscopic transperitoneal approach with intact specimen removal has become the standard technique for radical nephrectomies. We report the indications, techniques and oncological outcome in a single center experience.Patients and Methods: Between July 1999 and March 2003 we performed laparoscopic radical nephrectomies for renal cell cancer in 125 patients. Their initial staging, complications, and postoperative course were evaluated. During this period a total of about 1800 laparoscopic cases were performed. To date 82 patients were available for follow up data and have been analyzed for oncological outcome. Patients with primary metastatic disease were excluded from this analysis.Results: 123 procedures out of 125 were successful. In two cases (1.6%) conversion to open surgery was necessary due to bleeding (1 case) or bowel injury (1 case). In additional 3 cases (2.4%) intraoperative complications could be managed laparoscopically. In two cases (1.6%) postoperative bleeding lead to open revision for hemostasis. The mean tumor size was 5.1 cm (range 2-14 cm); median blood loss was 210 ml (range 50-900 ml). The mean surgical time was 200 min (range 90-435), including the learning curves of five surgeons. Histological findings were pT1 in 78 (62.4%), PT2 in 12 (9.6%) and pT3 in 28 (22.4%) patients. In 7 cases (5.6%) histology did not confirm malignant disease. Positive lymph nodes were detected in 3 cases (2.4%); surgical margins were negative for tumor in all patients. Follow-up was between 3 and 50 months with an average of 23.5 months. Disease progression was observed in 3 cases after 6, 11 and 12 months. No cases of local recurrence or port metastasis occurred during observation.Conclusions: Laparoscopic radical nephrectomy is a routine, effective treatment for patients with pT1-2NOMO renal cell carcinoma. With more experience a tumor up to 10-12 cm in size can be managed safely offering all the benefits of minimal surgery to the patients. Although no long-term follow-up is available our follow-up data up to 50 months confirm the effectiveness of laparoscopic radical nephrectomy in terms of surgical principles and oncological outcome. (C) 2003 Elsevier B.V. All rights reserved.

Die laparoskopische Tumornephrektomie hat in den letzten Jahren weltweite Verbreitung gefunden und ist in unserer Einrichtung eine Standardmethode der Therapie des Nierenzellkarzinoms. Dabei werden die klassischen Prinzipien der urologischen Onkologie unter Anwendung minimal-invasiver Techniken mit ihren Vorteilen umgesetzt.