Publications (15)25.86 Total impact
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Article: Feasibility of minimally invasive radical prostatectomy in prostate cancer patients with high prostate-specific antigen: Feasibility and 1-year outcomes.
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ABSTRACT: Objectives: Urologists are cautious to offer minimally invasive radical prostatectomy in prostate cancer patients with high prostate-specific antigen (and therefore anticipated to have locally advanced or metastatic disease) because of concerns regarding lack of complete cure after minimally invasive radical prostatectomy and of worsening of continence if adjuvant radiotherapy is used. Methods: A retrospective review of our institutional database was carried out to identify patients with PSA ≥20 ng/mL who underwent minimally invasive radical prostatectomy between January 2002 and October 2010. Intraoperative, pathological, functional and short-term oncological outcomes were assessed. Results: Overall, 233 patients met study criteria and were included in the analysis. The median prostate-specific antigen and prostate size were 28.5 ng/mL and 47 mL, respectively. Intraoperative complications were the following: rectal injury (0.86%) and blood transfusion (1.7%). Early postoperative complications included prolonged (>6 days) catheterization (9.4%), hematoma (4.7%), deep venous thrombosis (0.86%) and lymphocele (5.1%). Late postoperative complications included cerebrovascular accident (0.4%) and anastomotic stricture (0.8%). Pathology revealed poorly differentiated cancer in 48.9%, pT3/pT4 disease in 55.8%, positive margins in 28.3% and lymph node disease in 20.2% of the cases. Adverse pathological findings were more frequent in patients with prostate-specific antigen >40 ng/mL and (or) in those with locally advanced disease (pT3/pT4). In 62.2% of the cases, adjuvant radiotherapy was used. At 1-year follow up, 80% of patients did not show evidence of biochemical recurrence and 98.8% of them had good recovery of continence. Conclusion: Minimally invasive radical prostatectomy might represent a reasonable option in prostate cancer patients with high prostate-specific antigen as a part of a multimodality treatment approach.International Journal of Urology 07/2012; 19(10):923-7. · 1.75 Impact Factor -
Chapter: Lympadenectomy
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ABSTRACT: Current management options for low-stage malignant germ-cell testicular tumours after radical orchiectomy include surveillance, chemotherapy, or retroperitoneal lymph node dissection (RPLND). Open RPLND is the surgical gold standard but has a number of limitations. Firstly, approximately two-thirds of patients have either necrosis/fibrosis or pathologically negative nodes. Secondly, the operation results in a large scar and significant perioperative morbidity and convalescence. Laparoscopic retroperitoneal lymph node dissection has developed as a possible alternative to the open procedure. Currently, laparoscopic retroperitoneal lymph node dissection (L-RPLND) is not recommended as a standard therapeutic option in the European Association of Urology (EAU) guidelines. L-RPLND has, however, proved to be an excellent staging tool ,which should be developed as a less invasive alternative to primary open RPLND. As a staging tool, L-RPLND is performed usually without retrocaval or retroaortic dissection and is used to determine pathological status. The therapeutic value of this more limited dissection is not known and currently trials are underway to establish the therapeutic benefits. L-RPLND has been reported as efficacious compared to open RPLND for staging of the retroperitoneum in patients with stage I nonseminomatous germ-cell testis tumours (NSGCT). The rate of tumour control after L-RPLND and the diagnostic accuracy of L-RPLND were equal to the open procedure, and the morbidity was significantly lower [1, 2]. Therefore, L-RPLND for stage I and low-volume retroperitoneal stage II disease may be performed at experienced urology centres as part of ongoing trials [3, 4]. Loss of antegrade ejaculation is the most common long-term problem that the young men who undergo this operation experience. In an attempt to minimise this problem, either a template dissection or nerve-sparing RPLND should be performed. In a right template dissection, the right postganglionic fibres are resected whilst the left side ones are left intact. This applies to the left side also. Complete unilateral resection of the nerves should not result in loss of antegrade ejaculation. Dissection of both sides is only required in bilateral RPLND.05/2011: pages 169-185; -
Article: Isolated right testicular pain for six days: an unusual presentation of occult abdominal aortic aneurysm leak.
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ABSTRACT: Abdominal aortic aneurysm (AAA) rupture commonly presents with abdominal or lower back pain and haemodynamic instability. There have been case reports of co-existing left testicular pain;(1) however, very few cases describe right testicular pain as the sentinel symptom. We discuss the case of a 75-year-old man who presented to the on-call urologists with a 6-day history of right testicular pain. On examination, a painless AAA was detected. The patient was stable and a CT scan demonstrated a large AAA extending into the right iliac vessels, with suggestion of leakage. Attempted emergency repair was unsuccessful and the patient died in theatre. This atypical presentation of occult aneurysm leak highlights the need for clinical vigilance in the older patient with seemingly benign groin symptoms, including isolated right testicular pain.Annals of The Royal College of Surgeons of England 05/2011; 93(4):e1-2. · 1.23 Impact Factor -
Article: Yes to careful introduction of robot assisted surgery.
BMJ (Clinical research ed.). 01/2011; 343:d7215. -
Article: Could prostate biopsies be avoided in men older than 75 years with raised PSA?
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ABSTRACT: Our purpose was to review current practice regarding the use of prostate biopsies in men older than 75 years with raised PSA by presenting the results of a retrospective audit and to identify these older men who really benefit from prostate biopsies. A high-volume tertiary center's prospectively maintained prostate biopsy database of contemporary biopsies was reviewed. Men were stratified by age and PSA. Logistic regression analysis, Mantel-Haenszel and Fisher's exact tests were used for statistical analysis. Overall, 1,593 men underwent prostate biopsies between April 2004 and August 2006. Of these, 293 patients (18.4%) with a mean age of 82.62 years and mean PSA of 30.37 ng/ml were eligible for the study with an overall incidence of prostate cancer of 73.7%. Elderly men with PSA >20 ng/ml had a prostate cancer detection rate of 91%. They were more likely to have-high grade disease (OR = 5.4, 95% CI = 2.8-10.8, p < 0.0001) and receive hormone deprivation therapy (RR = 3.0, 95% CI = 2.1-4.3, p < 0.0001). Elderly men with PSA <20 ng/ml had a 3-fold risk of being placed on active monitoring. Almost 20% of them had 1 complication following biopsy, of whom 12 (4.1%) needed hospitalization. Given the high probability of detecting prostate cancer and receiving conservative treatment, prostate biopsies can be omitted in men >75 years with PSA >20 ng/ml. However, they are still useful in fit men >75 and <80 years with PSA <20 ng/ml who can be the potential candidates for treatment with curative intent.Urologia Internationalis 10/2010; 85(4):410-4. · 0.99 Impact Factor -
Article: Reduction in incidence of lymphocele following extraperitoneal radical prostatectomy and pelvic lymph node dissection by bilateral peritoneal fenestration.
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ABSTRACT: In our series of 1,900 endoscopic extraperitoneal radical prostatectomies (EERPE) the incidence of symptomatic lymphocele following simultaneous pelvic lymph node dissection (PLND) is between 3 and 14% depending on the extent of lymph node dissection. We report the impact of bilateral peritoneal fenestration after completion of extraperitoneal prostatectomy and PLND on the incidence of lymphocele, postoperative pain and complications. A total of 100 consecutive patients undergoing EERPE and extended PLND were allocated into two groups. In Group A (n = 50) a 4-6 cm incision was performed bilaterally over the external iliac vessels down to the obturator fossa after completion of the main procedure. In Group B (n = 50) no peritoneal incisions were made. The postoperative assessment protocol included a visual analogue pain scale administered three times daily for 6 days, analgesia requirement, and ultrasound examination on 4th and 8th days, and 3 months postoperatively. CRP and leucocyte counts were measured on 1st and 2nd postoperative days. Complications were recorded according to our standard protocol using the Clavien classification. Three patients (6%) in Group A were found to have lymphoceles, none of which were symptomatic. Significantly more patients in Group B developed a lymphocele, (n = 16, 32%, P < 0.001) of which a significant number were symptomatic (n = 7, 14%, P < 0.001) and required laparoscopic fenestration. No significant difference was observed between the pain score in either group. Mean pain scores were 3.4 versus 3.8 at 6 h, and 0.8 versus 1.1 at 6 days, respectively. No difference in analgesia requirement, serum inflammatory markers and return to normal bowel activity was observed between the groups. This study demonstrates that peritoneal fenestration significantly reduces the incidence of both symptomatic and asymptomatic lymphocele, without an increase in postoperative morbidity. As symptomatic lymphocele is one of the most common complications of extraperitoneal PLND requiring reintervention, we recommend that peritoneal fenestration should be performed routinely after extraperitoneal radical prostatectomy and PLND.World Journal of Urology 09/2008; 26(6):581-6. · 2.41 Impact Factor -
Article: Nerve-sparing endoscopic extraperitoneal radical prostatectomy.
BJU International 05/2008; 101(7):909-28. · 2.84 Impact Factor -
Article: Complications of endoscopic extraperitoneal radical prostatectomy (EERPE): prevention and management.
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ABSTRACT: Endoscopic extraperitoneal radical prostatectomy (EERPE) is a further advancement of minimal invasive surgery as it overcomes the limitations of laparoscopic (transperitoneal) RPE by the strictly extraperitoneal route of access combining the advantages of minimal invasive surgery with the advantages of an extraperitoneal procedure. Endoscopic extraperitoneal radical prostatectomy has many advantages but is not without complications. The aim of this review article is to describe the most common complications of this procedure. Complications associated with endoscopic extraperitoneal radical prostatectomy are: vascular injury--bleeding--haematoma, bowel injury, lymphocele, injury to the bladder--ureter, port site hernia, anastomotic leakage--stricture, obturator nerve injury--paralysis, gas embolism, catheter blockage, and miscellaneous like perineal pain, pubic osteitis, infection- urosepsis. The present review paper focuses on the identification and management of these complications The incidence of most complications directly correlates with the surgeons' experience, and the various complications are related to technical errors rather than to the technique itself. The laparoscopist performing endoscopic/ laparoscopic radical prostatectomy should be aware of all these complications. He should be able to recognise promptly, treat efficiently, and ideally prevent these complications.World Journal of Urology 01/2007; 24(6):668-75. · 2.41 Impact Factor -
Article: Anaesthetic considerations for endoscopic extraperitoneal and laparoscopic transperitoneal radical prostatectomy.
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ABSTRACT: We focus on the anaesthesiology and requirements for minimally invasive procedures for treating localized prostate cancer. The management of anaesthesia for laparoscopic and endoscopic radical prostatectomy (RP) can be more complex than expected. Numerous groups, especially early in their experience, have had problems (e.g. hypercarbia) with the anaesthesiology of the procedure. Co-operation between the surgeon and the anaesthesiologist is of paramount importance for a safe and effective laparoscopic or endoscopic RP. Nevertheless, the relative anaesthetic equipment and trained personnel should be available before embarking on such technically proficient procedures.BJU International 10/2006; 98(3):508-13. · 2.84 Impact Factor -
Article: Minimally invasive nephron-sparing surgery for renal cell cancer.
BJU International 09/2006; 98(2):278-84. · 2.84 Impact Factor -
Article: The economic impact of using alfuzosin 10 mg once daily in the management of acute urinary retention in the UK: a 6-month analysis.
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ABSTRACT: To calculate the economic consequences of using alfuzosin 10 mg once daily for managing acute urinary retention (AUR) related to benign prostatic hyperplasia (BPH). We examined whether alfuzosin use during hospitalization for AUR and for 6 months after a successful trial without catheter (TWOC) is cost effective compared to placebo and immediate prostatectomy, from the perspective of patients managed in the National Health Service (NHS) in the UK. A decision-analysis model was developed to estimate the costs of various treatment options within the first 6 months after a first episode of AUR. Clinical data were obtained from a large randomized clinical trial comparing alfuzosin 10 mg with placebo, and from published reports. Cost data were obtained from both NHS and resource-use data gathered during the clinical trial. A Monte Carlo analysis, allowing variability in all uncertain variables of the model, was used to calculate the uncertainty surrounding the results. Treating patients with alfuzosin during initial hospitalization for AUR and in the first 6 months after a successful TWOC generates a cost-saving of pounds 349 relative to placebo. Savings related to immediate prostatectomy were pounds 892; both savings were significant (P < 0.05). Alfuzosin treatment was associated with a lower rate of prostatectomy after discharge from hospital after a successful TWOC. Treatment with alfuzosin 10 mg once daily before and after a successful TWOC has both clinical and economic benefits. It decreases the need for emergency surgery for BPH and reduces treatment costs in the first 6 months.BJU International 10/2005; 96(4):566-71. · 2.84 Impact Factor -
Article: Quantitative morphometric analysis of individual resected prostatic tissue specimens, using immunohistochemical staining and colour-image analysis.
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ABSTRACT: To develop a method for obtaining morphometric measurements representative of individual chips from transurethral resection of the prostate (TURP). In all, 232 sections were cut in pairs from 25 TURP chips, collected from four patients undergoing TURP for benign prostatic hyperplasia. Individual tissue chips were processed, embedded in paraffin wax and pairs of neighbouring sections cut from the specimens at intervals of 300 microm throughout the thickness of the specimen. Of each pair, the epithelial tissue (ET) of one and the smooth muscle (SM) of the other section were stained immunohistochemically with anti-prostate-specific antigen and anti-SM myosin, respectively. Proportions of ET and SM within the sections were measured with colour-image analysis and calculated within the TURP chips using all pairs of sections cut from the specimen, and the first pair of sections only. The differences between the sets of results were analysed using descriptive statistics. From each TURP chip, 3-7 pairs of sections were cut; for both ET and SM within each chip the differences between the results calculated using data from all pairs of sections and the first pair alone were small, as were the distributions of these differences within each prostate. Morphometric measurements from one section from a processed TURP chip, as opposed to serial sections, can be used to reliably assess the morphology of tissue within that specimen. This permits a considerable saving of resources when undertaking morphometric image analysis of resected prostatic tissue specimens.BJU International 11/2004; 94(6):919-21. · 2.84 Impact Factor -
Article: Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma: a critical appraisal.
BJU International 09/2004; 94(3):259-63. · 2.84 Impact Factor -
Article: Training in Laparoscopy
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ABSTRACT: ObjectiveTraining in laparoscopy is still a challenge for the urologic community. Surgeons in training must learn the laparoscopic techniques, possibly without having ever performed the conventional procedure. In the present study, we provide a nonstructured literature review pertaining to laparoscopic training and discuss the training design and the modular concept.MethodsA thorough literature search was performed with the Medline database and different training procedures were analysed.ResultsDue to increasing time constraints, cost, stress, and ethical considerations, the modern operating room is not the ideal learning environment. Various simulators and models for laparoscopic training in urology and general surgery with different levels of validity and reliability are available. Wide acceptance of the use simulators has been hampered by the lack of standard and valid methods to measure and certify competence in basic psychomotor skills. Besides, it is unclear if trainees have enough access to these programmes and if they are sufficient enough to develop the required skills. Whether complex urologic procedures can be performed by beginners without open surgical expertise and whether experience in open surgery is definitely required before mastering laparoscopic techniques are still matters of issue.ConclusionThe lack of a standardised, evaluated training procedure needs to be overcome. Structured training programmes and transference of gained experience into daily practice are essential to provide urology with expert laparoscopists.EAU-EBU Update Series. -
Article: Surgical Atlas Nerve-sparing endoscopic extraperitoneal radical prostatectomy
Top co-authors
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Institutions
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2011
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NHS Lothian
Edinburgh, SCT, United Kingdom
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2006–2008
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University of Leipzig
Leipzig, Saxony, Germany
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