At 05.30 the "5 km fun run" was run by about 200 people, protected by a vigil police force.
"Put away your butchers knife and let me save this man before it is too late". These words were spoken in a 1987 'StarTrek' movie and was the starting point for the State-of-the-Art lecture by Clayman about laparoscopic urology. Everything that can be done, has been done, although the learning curve for laparoscopy is considerable and varies between 30-50 patients. It will always take more time than conventional surgery. Estabished indications for laparoscopic surgery are cryptorchidism and lymphocele. Laparoscopic varicocele treatment is obsolete. Possibilities exist in nephropexy, colposuspension and renal cysts (200 cases worth of experience in laparoscopic cyst treatment with a lasting effect but without compromising kidney function, were shown at this convention). One should be warned for the general surgeon who also gains experience in laparoscopic nephrectomy (for transplantation), adrenals and retroperitoneal lymphnode dissections.
The laparoscopic podium session, a study on 36 tumor nephrectomies for small tumors was presented by dr. Ono (818). Most serious complication was perforation of the duodenum; the procedures took 5.2 hours on average. Ono could not get the hospital stay down. In Germany, Thuroff (825) sees no advances in laparoscopic nephrectomy compared to open procedures, while laparoscopic surgery is more expensive. The same goes for colposuspensions (821, 822).
Like I wrote before, the Holmium or Holmium-NdYag laser will probably be the next generation urologic laser. Kabalin showed that this laser can be used in any endo-urologic procedure using different energy-setups: lithotripsy, ureteric and urethral strictures, bladder tumor resection and/or vaporization, prostate vaporization or resection, endo-pyelotomy et cetera. It abolishes the use of other methods for lithotripsy or electro-coagulation and can thus save money.
Shlomo Raz told us of his experiences with 3000 vaginal procedures. The vaginal sling technique now is done in day care and takes 20 minutes. He claims a 95% success rate after 4 years (third party retrieved data) and no urinary retentions. Video demonstrations followed. The discussion dealt with nasty problems like acid free diets and physiotherapy in interstitial cystitis, indications for adhesiolysis in chronic pelvic pain and diagnostic procedures before urethral diverticulum surgery.
The "new tricks with old drugs" story of Schaeffer showed ever more bacterial resistance against antibiotics, which forces new treatment strategies. Aminoglycosids show a post antibiotic effect, meaning that bacteria are unable to divide and grow 4-5 hours after the plasma concentration has dropped below the MIC. It follows that one daily dose of an aminoglycosid (7mg per kg) is more effective, safer and cheaper than the old schemes. If creatinin clearance is low, then even less frequent schemes must be used. The effectiveness of quinolones can be increased by in increasing the dose, for example to 2dd 750mg. Quinolones are to be reserved for use in complicated urinary infections only. Fluconazole orally works well against candida cystitis.
"The Government treats doctors like they treated indians last century" signifies the statement from Holtgrewe when he talked about health policy initiatives. Many commitments are later proven void. The AUA opposes the downward spiral of ever lower incomes. A TURP has gone down from $ 1500 to $ 600. The coming year a major fiscal check on urologists is expected.
"In the ICSI-era there is no place anymore for urologists and their knowledge of male infertility". This gynecological statement was proven wrong during the last panel discussion of the morning. ICSI (Intra Cytoplasmatic Semen Injection) is a big leap in the treatment of infertility in case of very low sperm counts or azoospermia. As a prenatal analysis, one cell of the morula stage can be harvested to detect inborn defects. ICSI will lead to a birth percentage of 27 per cycle. Main factor determining success is the age of the female. American studies show no increase in the percentage of birth defects (2.6%). Turek showed vasovasostomy and vasoepididymostomy to be a viable alternative, and cheaper than ICSI. If one vasovasostomy fails to deliver in case of oligo- or azoospermia then another vasovasostomy is indicated (Carbone, 655).
Cranston (659) presented the results of semen analysis after vasectomy in 4700 cases; in 4% living sperm cells could be found in the second analysis, while the first was sterile.
"Men with neo bladders had more difficulty in psycho-social adaptation to life after radical cystectomy than patients with conduit or continent urinary diversion". A Swedish group (915) thus concluded their study in 57 patients after radical cystectomy. Predominantly a loss of self esteem, it may be caused by higher preoperative expectations when compared to patients who underwent a Bricker deviation or received a continent pouch. A 19 year followup showed that a Bricker deviation may lead to renal insufficiency in 12 of 28 patients and death in 9; in 70% of survivors kidney stones formed (Dowling, 917). Von Knobloch (920) showed that continent deviations were also possible in 12 patients after kidney transplants. The pouch or orthotopic bladder is constructed before transplant. 5 of these patients underwent kidney transplants and now have normal plasma creatinin levels after an average follow up of 20 months.
Since 300 of 1800 abstracts deal with prostate cancer, we saw some more of this topic. The optimal number of biopsies is still unclear, although the number of false-negative biopsies can be decreased when the biopsies are taken as far lateral in the prostate as possible.
van den Ouden (154) found that vasoinvasive growth is an important bad prognostic sign in prostate cancer. Cryotherapy of the prostate does not seem to be as promising as it once was; if biopsies are still positive after cryo, then external radiotherapy may help. (988).
Adjuvant radiotherapy after radical prostatectomy in T3 tumors is currently investigated in a EORTC study. Bocon Gibod (poster 1118) showed that a small number of patients later develop PSA failure. The choice of treatment should mainly be governed by co-morbidity, which, especially in the elderly, proves to be more important for survival than the tumor itself. l
Lieskovsky (1246) uses adjuvant radiotherapy (only 48 Gy) in T3 tumors post radical prostatectomy, but finds recurrence in 4% after 10 years.
The treatment of metastasis from prostate cancer in patients with bad prognostic signs showed serious toxicity for mitomycin therapy without improvement on survival or symptoms. This represents the definitive result of a EORTC study presented by De Reijke (1249).
Van Andel (1255) stated that late hormonal treatment in lymphnode positive patients results in a better quality of life. Prospective randomized studies will show, in the coming years, how to best treat patients with PSA failure after radical prostatectomy or radiotherapy, or patients with positive nodes; average life expectancy in this group is 5-7 years. An early start of hormonal treatment may cause adverse effects like osteoporosis, while it is still unknown if early treatment will increase survival.
Janknegt presented the good results of Foramen S3 electrodes in otherwise untreatable urge-incontinence (1237). Van Alewijk (1351) found a homozygote deletion on chromosome 8P12-P21 in cases of prostate cancer, maybe the location of a tumor-suppressor gene. Rosier (1377) discovered spinal cord anomalies in patients with multiple sclerosis using MRI.
More of this tomorrow.
| ENGLISH version | | DUTCH version 12 April 199713 April 199714 April 199715 April 199716 April 1997 |