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Jens Rassweiler

Publications and source records attributed to Jens Rassweiler.

At least 19 recordsLinked to original sources
PubMed2006

A new postoperative predictor of time to urinary continence after laparoscopic radical prostatectomy: the urine loss ratio.

OBJECTIVES: To assess the correlation of a newly defined parameter, "urine loss ratio" (ULR), with the time to continence and probability for incontinence after laparoscopic radical prostatectomy (LRP). MATERIALS AND METHODS: A standardized "micturition protocol" that uses 24-h pad testing to objectively quantify urine loss after removal of the catheter was obtained from 939 patients who underwent LRP and were provided complete follow-up regarding continence. ULR was defined as the weight of urine loss in the pad divided by daily micturition volume, distinguishing between ULR on the first day after catheter removal and the last day of hospital stay. The time to continence was classified as early (0-3 mo), midterm (4-12 mo), and late continence (13-24 mo). RESULTS: Early continence was attained in 69.8% (n=655) of patients, midterm continence in 18.4% (n=173), and late continence in 3.5% (n=33). Of 939 patients in whom first-day ULR was quantified, 495 patients were not discharged immediately and their last-day ULR was quantified (2.3 d following catheter removal). There was a linear correlation between time to continence and ULR, which was more significant for last- than first-day ULR (p<0.001). A cutoff point of more than 15% of urine loss indicates a high risk of incontinence (ie, 8-fold for first-day ULR, 55-fold for last-day ULR). CONCLUSION: ULR predicts the time to continence and may be used to select patients for specific rehabilitation programs and early adjuvant medical therapy, particularly when urine loss exceeds 15%.

Adult↗
PubMed2006

The radius surgical system - a new device for complex minimally invasive procedures in urology?

OBJECTIVE: Complex laparoscopic procedures in urology are technically demanding with an extended learning curve. Robotic systems add significant cost to laparoscopic procedures. We therefore evaluated the use of the Radius Surgical System (RSS), a mechanical manipulator, for complex laparoscopic cases in urology. MATERIAL AND METHODS: The RSS (Tuebingen Scientific) consists of two hand-guided surgical manipulators and provides a deflectable and rotatable tip allowing six degrees of freedom. We evaluated the system by using a series of standardized models in the pelvitrainer. We analyzed the effectiveness of the system and the learning curve. We then evaluated the system in the clinical setting during laparoscopic radical prostatectomy. RESULTS: Surgeons with experience on the RSS were compared to surgeons without previous experience on the system. We identified a learning curve in those participants without experience on the system only when performing complete anastomoses in the pelvitrainer. However, this learning curve included less than 10 anastomoses. The first clinical experiences during laparoscopic extraperitoneal radical prostatectomy (n=10) are promising. All anastomoses were patent on routine (X-ray) examination 8 days after surgery. CONCLUSIONS: The RSS system is easy to use and we identified a very short learning curve. We now optimize the system for use in urology. This device may facilitate complex laparoscopic procedures without the use of costly robotic systems and should be further evaluated in the experimental and clinical setting.

Equipment Design↗
PubMed2006

Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention.

OBJECTIVES: To update the complications of transurethral resection of the prostate (TURP), including management and prevention based on technological evolution. METHODS: Based on a MEDLINE search from 1989 to 2005, the 2003 results of quality management of Baden-Württemberg, and long-term personal experience at three German centers, the incidence of complications after TURP was analyzed for three subsequent periods: early (1979-1994); intermediate (1994-1999); and recent (2000-2005) with recommendations for management and prevention. RESULTS: Technological improvements such as microprocessor-controlled units, better armamentarium such as video TUR, and training helped to reduce perioperative complications (recent vs. early) such as transfusion rate (0.4% vs. 7.1%), TUR syndrome (0.0% vs. 1.1%), clot retention (2% vs. 5%), and urinary tract infection (1.7% vs. 8.2%). Urinary retention (3% vs. 9%) is generally attributed to primary detrusor failure rather than to incomplete resection. Early urge incontinence occurs in up to 30-40% of patients; however, late iatrogenic stress incontinence is rare (<0.5%). Despite an increasing age (55% of patients are older than 70), the associated morbidity of TURP maintained at a low level (<1%) with a mortality rate of 0-0.25%. The major late complications are urethral strictures (2.2-9.8%) and bladder neck contractures (0.3-9.2%). The retreatment rate range is 3-14.5% after five years. CONCLUSIONS: TURP still represents the gold standard for managing benign prostatic hyperplasia with decreasing complication rates. Technological alternatives such as bipolar and laser treatments may further minimize the risks of this technically difficult procedure.

Humans↗
PubMed2006

Laparoscopic and robotic assisted radical prostatectomy--critical analysis of the results.

OBJECTIVE: To evaluate the role of laparoscopic radical prostatectomy (LRP) and robotic assisted radical prostatectomy (RLRP) based on personal experience and a review of the literature. MATERIAL AND METHODS: Own experience at one European and one American LRP-center includes more than 2000 cases. We performed a MEDLINE search reviewing the literature on LRP and RLRP between 1992 and 2005 with special emphasis on historical aspects, technical considerations, comparison to open retropubic (RRP) and perineal radical prostatectomy (PRP), laparoscopic training, and the cost-efficiency of the techniques. RESULTS: Based on sophisticated training programs a continuous dissemination of the technique took place. In the United States, this process was accelerated by the use of the daVinci-robot. There is a trend towards the extraperitoneal access. Mid-term outcomes of LRP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower rate of complications, shorter convalescence, and better cosmesis. In contrast to RLRP, LRP may reach cost-equivalence with open surgery (i.e. by reduction of OR-time, use of multi-usable instruments). CONCLUSIONS: LRP reproduces the excellent results of open surgery providing the advantages of minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow. In contrast the United States, the use of robots is likely to remain limited in Europe.

Cost-Benefit Analysis↗
PubMed2006

Laparoscopic transvesical urethrorectal fistula repair: a new technique.

INTRODUCTION: Urethrorectal fistulas are rare, and several open operative approaches and techniques have been used in treatment. We report our preliminary experience with laparoscopic transvesical urethrorectal fistula repair after iatrogenic urethrorectal fistula. A 65-year-old man with insulin-dependent diabetes mellitus and peripheral vascular disease was hospitalized 6 months after transurethral resection of the prostate for benign prostatic hyperplasia with a recurrent urinary tract infection, fecaluria, and urine leakage from the rectum during voiding. Urethrocystoscopy revealed a urethrorectal fistula in the prostatic fossa. Primary conservative treatment failed. TECHNICAL CONSIDERATIONS: The patient was placed in the lithotomy position, and the suprapubic tract was dilated to allow a 10-mm telescope. Carbon dioxide gas was used to distend the bladder (15 mm Hg, flow rate 3 L/min). Next, two 3-mm pediatric trocars were inserted under direct vision. The fistula was identified and the edge of the fistula excised. A running suture (3-0 PDS, RB needle) was used to close the fistula. Finally, a 16F Foley urethral catheter was passed under direct vision, followed by a suprapubic catheter. On postoperative day 12, retrograde cystography revealed no contrast leakage from the rectum. Follow-up after 3 months showed no recurrence of the fistula. CONCLUSIONS: A transvesical laparoscopic technique might be useful for selective cases of urethrorectal fistula. Other methods of laparoscopic urethrorectal fistula repair have included bivalving of the bladder and omental interposition. The laparoscopic transvesical approach provides many advantages, including easy access and identification of the fistula tract, good surgical exposure, and minimal tissue manipulation.

Aged↗
PubMed2006

Anatomic nerve-sparing laparoscopic radical prostatectomy: comparison of retrograde and antegrade techniques.

OBJECTIVES: To compare the anatomic retrograde and antegrade preservation of the neurovascular bundle (NVB) during laparoscopic radical prostatectomy. METHODS: Anatomic studies were reviewed, focusing on the fascial layers surrounding the prostate and NVB and the terminology used as described by Walsh and colleagues. Important operative steps have been illustrated using video clips. For the retrograde technique, after incision of levator fascia, the NVBs were released from the apex before division of the urethra. Along the plane between the laterally incised Denonvilliers and perirectal fascia, the prostate was mobilized from the rectum. Isolated clipping of the seminal vesicle arteries was performed in an antegrade manner, followed by control of the lateral pedicles, and identification of the course of the NVB. For the antegrade technique, after dissection of the seminal vesicles, the levator fascia was incised to develop a lateral NVB groove. After bladder neck division and lateral pedicle ligation, the lateral NVB groove was used as a guide for antegrade preservation of the NVB. During anastomosis, the NVBs located at the 5-o'clock and 7-o'clock positions were avoided in both techniques. RESULTS: A questionnaire-based potency rate of 67% and 76%, respectively, was reported after bilateral nerve sparing using retrograde and antegrade laparoscopic radical prostatectomy techniques. CONCLUSIONS: Both techniques allowed replication of open surgical principles. The video magnification enabled excellent demonstration of the periprostatic anatomy. The principles of interfascial dissection of the NVB, use of task-specific instrumentation, and avoiding energy sources around the NVB may be more important than the actual nerve-preservation technique used.

Humans↗
PubMed2006

The impact of neoadjuvant hormonal therapy on the outcome of laparoscopic radical prostatectomy: a matched pair analysis.

PURPOSE: We evaluated the effect of androgen ablation treatment on laparoscopic radical prostatectomy operative and postoperative parameters. MATERIALS AND METHODS: A total of 50 patients (group 1) on neoadjuvant androgen deprivation, followed by laparoscopic radical prostatectomy, were compared to 50 (group 2) without any treatment who were matched for prostate volume, laparoscopic pelvic lymphadenectomy, nerve sparing procedure, surgical access type and pathological stage. We analyzed operative time, blood loss, intraoperative and postoperative complications, catheter time, procedure difficulty as scored by the surgeon and surgical margin status. RESULTS: There was no significant difference between the neoadjuvant and nonneoadjuvant groups with respect to mean operative time +/- SD (228.6 +/- 62.9 vs 219.4 +/- 65.1 minutes), mean blood loss (667.6.1 +/- 217.1 vs 729.8 +/- 285.1 ml) and median catheter time (7 vs 7.5 days). We also found no difference related to the complication rate. Ten of 50 prostate dissections (20%) in group 1 were classified as difficult, whereas in group 2 only 4 of 50 (8%) were scored as difficult (p = 0.084). The positive surgical margin rates did not differ. CONCLUSIONS: There was no significant difference with respect to operative or postoperative parameters in patients undergoing neoadjuvant androgen ablation therapy compared to controls. At centers where there is experience laparoscopic radical prostatectomy can be safely performed in patients who have undergone neoadjuvant hormonal therapy.

Androgen Antagonists↗
PubMed2005

Laparoscopic radical prostatectomy--the experience of the German Laparoscopic Working Group.

PURPOSE: To present the current status of laparoscopic radical prostatectomy (LRP) in Germany, Austria and Switzerland with respect to transferability, learning curve, and outcome. MATERIAL AND METHODS: The data of 5824 patients who underwent LRP in 18 centers by 50 urologists from March 1999 to August 2004 were analyzed retrospectively. Three centers performed more than 500, and six more than 250 cases. A transperitoneal descending technique with was used in 2701, a transperitoneal ascending in 1234, an extraperitoneal descending in 1814, and an extraperitoneal ascending modification in 75 cases. Specimen showed pT2 in 3535, pT3a in 1555, pT3b in 623, and pT4 in 111 cases. RESULTS: Mean operating time averaged 211 (131-292) minutes, with shorter duration of the extraperitoneal descending technique. Conversion to open surgery averaged 2.4 (0-14.1) %. Re-intervention rate amounted to 2.7 (0.3-7.7) %. Complication rate averaged 8.9 (1.8-10.8) % including bleeding (0.3-2.5%) and rectal lesion (1.5-2.5%). The rate of positive margins was 10.6 (3.2-18) % for pT2- and 32.7 (20-38.5) % for pT3a-tumors Continence after 12 months was 84.9 (72-94) %. Data about potency (7 centers) revealed 52.5 (35-67) % full erections following bilateral nerve preservation. 5 year-PSA recurrence rate (3 centers) was 8.6 (4-15.3) % for pT2-tumors and 17.5 (15-20.6) % for pT3a-stages. CONCLUSIONS: The results confirm the efficacy of the training program with safe transfer of LRP (i.e. low complication rate), however including all known problems of a retrospective study.

Adult↗
PubMed2005

Laparoscopic radical prostatectomy: prospective evaluation of the learning curve.

OBJECTIVE: We prospectively evaluated the learning curve (LC) of laparoscopic radical prostatectomy (L-RPE) regarding the improvements in operative times (OT) and technical difficulty in one-operator-practice as it compares with open RPE. METHODS: Over 18 months, 50 L-RPE were performed by an inexperienced surgeon in laparoscopy but skilled in open surgery. Difficulty scores were obtained at the completion of each L-RPE comparing L-RPE to open RPE. OT, estimated blood loss (EBL), length of stay, and catheterization time were also obtained. RESULTS: In the ablative part of L-RPE the median difficulty score was significantly higher (p<0.001) for the first 10 cases, decreased dramatically by case 11 becoming equivalent (p=0.3) to open RPE and by case 31 the L-RPE becomes significantly easier than open RPE (p=0.002). The difficulty scores for the urethrovesical anastomosis performance is always uniformly higher for the whole patient series (p<0.001). Median OT decreased significantly from 293 minutes in the first 10 cases to 114 minutes in the last 10 cases (p<0.001). Catheterization time and length of hospitalization, decreased significantly with the progression of the LC. EBL remained stable throughout the patient cases. Obesity, prior surgery, and extension of the procedure (lymphadenectomy, nerve-sparing) significantly increased the OT. CONCLUSION: Although the ablative part of L-RPE has a relatively short LC for a skilled open surgeon reflected by the rapid decrease in difficulty scores and OT by case 21, the performance of anastomosis shows a longer LC. Intensive training on anastomosis may be necessary to master this skill.

Aged↗
PubMed2005

Prosthetic mesh hernioplasty during laparoscopic radical prostatectomy.

OBJECTIVES: To evaluate the role of simultaneous laparoscopic mesh prosthetic hernioplasty during laparoscopic radical prostatectomy (LRP), because 5% to 10% of candidates for radical prostatectomy present with a detectable inguinal hernia at their preoperative physical examination. Moreover, data have suggested a greater incidence of inguinal hernia after open radical prostatectomy. METHODS: During 1035 LRP procedures, 50 laparoscopic mesh prosthetic hernioplasty procedures were performed in 37 patients (3.6%) for 13 bilateral and 24 unilateral inguinal hernias. We compared the outcome of LRP with simultaneous laparoscopic inguinal hernioplasty (group 1) with that of 37 match-paired patients treated by LRP alone (group 2). Both groups were matched according to age, prostate-specific antigen level, prostate volume, pathologic stage, and Gleason score. Perioperative parameters (ie, operative time, analgesic requirements) and postoperative results were analyzed. RESULTS: The patient age was 64.1 +/- 6.4 years versus 62.8 +/- 4.9 years old and had a body mass of 26.5 +/- 3.0 versus 27.4 +/- 3.2 kg/m2 in groups 1 and 2 (with and without laparoscopic hernioplasty), respectively. The mean operating time (221.9 versus 191.2 minutes, P = 0.011) and the total amount of narcotic analgesic requirements (26.8 mg versus 17.5 mg, P = 0.026) was significantly increased in the patients who underwent simultaneous laparoscopic inguinal hernia mesh repair. No statistically significant difference was found in the complication rate (4% versus 2%), median catheter time (7 days), and positive surgical margins (21.8%). CONCLUSIONS: Simultaneous repair of inguinal hernia during LRP using prosthetic mesh is feasible without adverse effects on surgical and functional parameters. Neither the transperitoneal nor extraperitoneal approach is associated with an increase in complications or morbidity. However, an extraperitoneal access allows an easier repair without the refixation of the peritoneum.

Digestive System Surgical Procedures↗
PubMed2005

Laparoscopic radical prostatectomy--impact of training and supervision.

To define the influence of training and supervision on the quality of laparoscopic radical prostatectomy we compared our perioperative parameters, as well as the postoperative functional and oncological outcomes of four generations of surgeons with significantly different training modalities. The first two generations were trained in open retropubic radical prostatectomy, but the third and fourth generation were trained mostly laparoscopically. Overall the data of more than 1000 performed cases were compared: We could not find any significant difference concerning our complication rates. Also the data of oncological (positive margins) and functional results (data of continence with a follow-up of more than two years) were comparable within all groups. A learning curve was observed only for the operating time, but proved to be significantly shorter for the third and fourth generations. Therefore we can conclude that the quality of laparoscopic radical prostatectomy does not depend on the individual experience in open surgery but to a considerable extent on the quality of laparoscopic education (e.g. simulation trainer, supervision).

Journal Article↗
PubMed2005

Laparoscopic radical cystectomy with and without orthotopic bladder replacement.

The successful introduction of laparoscopic radical prostatectomy at the end of the last millennium represented a quantum leap in the technical development of minimally invasive surgery in urology. Therefore it seemed a logical step that, at the beginning of this millennium, first centers reported their initial experience with laparoscopic radical cystectomy. Based on more than 2000 laparoscopic radical prostatectomies, two centers have performed this procedure in 48 patients including a variety of urinary diversion (i.e. ileal conduit, ileal neobladder, sigmoid neobladder). In this article, all important surgical steps of laparoscopic radical cystectomy are presented, including the description of the most important techniques of urinary diversion. Based on our own experience, the results of 238 cases presented in the current literature are reviewed. The operating time mainly depended on the type and technique of urinary diversion and ranged between 352 and 430 minutes for ileal conduit, and between 478 and 649 minutes for orthotopic neobladder. The complication rate ranged between 16 and 18%, and the reintervention rate was 4-6%. Long-term follow-up is not available, disease-free survival after three years in a limited number of series ranges between 50 and 67%. No port site metastases have been reported so far. Even for the experienced surgeon laparoscopic radical cystectomy with urinary diversion represents a technically challenging procedure. Nevertheless, feasibility and safety have been proved by various authors. However, larger studies with long-term clinical outcome are necessary to determine the final value of the procedure.

Journal Article↗
PubMed2005

The Heilbronn laparoscopic training program for laparoscopic suturing: concept and validation.

BACKGROUND AND PURPOSE: More than a decade after the first description of laparoscopic nephrectomy, an increasing number of laparoscopic procedures are being performed worldwide. Nevertheless, there still exists a significant lack of standardized training programs to teach ablative and, most important, reconstructive laparoscopic operations (i.e., pyeloplasty, radical prostatectomy). We evaluated and validated a new standardized step-by-step program to improve laparoscopic skills and enable trainees not experienced in laparoscopy to perform a urethrovesical anastomosis. MATERIALS AND METHODS: In an inanimate model (pelvic trainer) with defined trocar positions, the 10 participants were exposed to six reconstructive exercises. The steps consist of improvement of hand-eye coordination (two-row metal-pin model; step I), linear and curved suturing with changing angles of the needle (chicken leg and catheter model; steps II-V), and performance of an anastomosis in a porcine bladder (step VI). Times of 3, 15, 15, 10, 20, and 30 minutes for steps I, II, III, IV,V, and VI, respectively, were defined as the goal before proceeding to the next stage. The time required to succeed in each step and the increase in the speed of suturing and knotting activities were analyzed with the Wilcoxon signed-rank test. RESULTS: After a mean of 40 hours of training, all participants were able to perform all steps within the specified times and complete an accurate urethrovesical anastomosis in 30 minutes. The time required to succeed before and after training showed a significant decrease (P < 0.05). Continual training in reconstructive procedures decreased the time needed for suturing activities by between 66.3% and 72.2%. The time needed for the knotting activities decreased by between 34.3% and 38.3%. CONCLUSIONS: Our program enabled participants not experienced in laparoscopy to increase reproducible performance in reconstructive laparoscopy. These results indicate that the challenging parts of reconstructive laparoscopy such as intracorporeal suturing can be taught using a standardized concept. This experience could be incorporated easily by every department developing a laparoscopic training program.

Anastomosis, Surgical↗
PubMed2005

The effect of previous transperitoneal laparoscopic inguinal herniorrhaphy on transperitoneal laparoscopic radical prostatectomy.

PURPOSE: Previous laparoscopic herniorrhaphy has been considered a contraindication to laparoscopic radical prostatectomy (LRP). In this study we analyzed the impact of previous laparoscopic or open inguinal hernia repair on the outcome of transperitoneal laparoscopic radical prostatectomy using the Heilbronn technique. MATERIALS AND METHODS: In our database of 1,089 patients with LRP we identified 20 who underwent transperitoneal LRP and had a history of transperitoneal laparoscopic inguinal herniorrhaphy using prosthetic mesh (group 1). The outcome in that group was compared to that of 20 matched pair patients of a total of 95 in whom LRP was performed following open inguinal herniorrhaphy (group 2) and 20 matched pair patients of a total of 771 without previous surgery (group 3). Perioperative parameters (operative time, blood donation and complications) and postoperative results (duration and amount of analgesic treatment, catheterization and the continence rate) were analyzed. RESULTS: According to the matched pair algorithm the 3 groups did not differ with respect to age (63.8, 66.2 and 63.0 years, p = 0.226), prostate volume (47.2, 43.3 and 47.7 gm, p = 0.501) or body mass index (26.1, 25.8 and 26.2 kg/m, respectively, p = 0.641). Ten pelvic lymphadenectomies and 8 nerve sparing (4 unilateral and 4 bilateral) procedures were performed per group. Ten and 12 patients in groups 1 and 2 had a history of bilateral herniorrhaphy, while previous unilateral herniorrhaphy was noted in the remaining 10 and 8, respectively. Mean operative time +/- SD (203.3 +/- 3.54, 196.7 +/- 43.7 and 214.7 +/- 37.7 minutes, p = 0.346) and mean catheterization time (8.1 +/- 2.8, 7.7 +/- 2.5 and 7.4 +/- 2.1 days, respectively, p = 0.684) did not differ significantly among the 3 groups. However, the mean amount of narcotic analgesic was significantly higher in group 1 compared with groups 2 and 3 (32.1 +/- 11.9, 21.8 +/- 11.9 and 19.5 +/- 10.1 mg, respectively, p = 0.002). Continence rates were similar in the groups at 88%, 87% and 92%, respectively, 1 year after surgery. CONCLUSIONS: Previous laparoscopic inguinal herniorrhaphy using prosthetic mesh does not adversively affect the operative outcomes or functional results of LRP, while the total amount of narcotic analgesics was significantly higher, reflecting increased postoperative morbidity.

Aged↗