Stavros Tyritzis | Karolinska University Hospital (original) (raw)

Papers by Stavros Tyritzis

The Italian journal of urology and nephrology, Jul 1, 2019

BACKGROUND Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in u... more BACKGROUND Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in urology, that is not devoid of postoperative complications. Minimally invasive surgery, and especially robot-assisted radical cystectomy (RARC) has emerged as an alternative to open radical cystectomy (ORC) in an attempt to minimize surgical morbidity and facilitate the surgical approach. The aim of this paper is to present the current knowledge on the oncological efficacy and complication outcomes of RARC. METHODS A non-systematic review on all relevant studies with the keywords radical cystectomy, open, robot-assisted, complications, recurrence, survival, neobladder, potency, continence and intracorporeal was performed using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) Guidelines. RESULTS RARC shows similar lymph node yields and positive surgical margin rates as well as perioperative complication outcomes compared with ORC. RARC exhibits significantly less blood loss and less intra- and postoperative blood transfusion. Moreover, survival and recurrence rates are not related to the surgical approach. Finally, RARC seems to be more expensive and has a longer operating time compared to the open technique. CONCLUSIONS As current evidence shows, RARC seems as a technically feasible and safe procedure, providing equivalent perioperative and oncological results compared to ORC. More prospective, randomized-controlled trials are necessary to draw definitive conclusions on all comparative aspects.

The Italian journal of urology and nephrology, May 1, 2019

Referring to the article published on pp. x-y of this issue

International Journal of Urology, Nov 26, 2017

In 2018, robot-assisted radical cystectomy will enter its 15th year. In an era where an effort is... more In 2018, robot-assisted radical cystectomy will enter its 15th year. In an era where an effort is being made to standardize complication reporting and videos of the procedure are readily available, it is inevitable and justified that like everything novel, robot-assisted radical cystectomy should be scrutinized against the gold standard, open radical cystectomy. The present comparison is focused on several parameters: oncological, functional and complication outcomes, and direct and indirect costs. Metaanalysis and prospective randomized trials comparing robot-assisted radical cystectomy versus open radical cystectomy have been published, showing an oncological equivalence and in some cases an advantage of robot-assisted radical cystectomy in terms of postoperative morbidity. In the present review, we attempt to update the available knowledge on this debate and discuss the limitations of the current evidence that prevent us from drawing safe conclusions.

Journal of Endourology, Feb 1, 2015

A ureteral stricture is a rather rare urological event defined as a narrowing of the ureter causi... more A ureteral stricture is a rather rare urological event defined as a narrowing of the ureter causing a functional obstruction and renal failure, if left untreated. The aim of this review article is to summarize and discuss current knowledge on the incidence, pathogenesis, management, and follow up of proximal, mid, and distal ureteral strictures.

Springer eBooks, Jul 21, 2013

Robot-assisted radical cystectomy and urinary diversion is gaining an increasing worldwide accept... more Robot-assisted radical cystectomy and urinary diversion is gaining an increasing worldwide acceptance. In this chapter, we describe all necessary surgical steps and discuss all preoperative, intraoperative and postoperative matters concerning the urinary diversion with a totally intracorporeal construction of an orthotopic ileal neobladder using the DaVinci robotic system.

Minerva Chirurgica, 2019

INTRODUCTION The extent of lymph node dissection (LND) and its potential survival benefit are sti... more INTRODUCTION The extent of lymph node dissection (LND) and its potential survival benefit are still a matter of debate. Aim of our review was to summarize the latest literature data regarding the surgical templates, the potential oncological benefits, the functional outcomes and the complications of extended lymph node dissection (eLND) during robot-assisted radical prostatectomy (RARP). EVIDENCE ACQUISITION We systematically reviewed all relevant studies using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) guidelines. EVIDENCE SYNTHESIS A narrative synthesis of all relevant publications on surgical templates, complications, oncological and functional outcomes of robot assisted eLND was undertaken. CONCLUSIONS A great deal of evidence supports that an extended template of LND is not only technically feasible but also safe in the context of RARP. It is really promising that in the era of minimally invasive surgery, parameters like the lymph node yield and the detection rates of positive lymph nodes during LND have become highly comparable with open series. The extended approach has already proved its benefits in terms of proper patient staging but more studies are needed with regard to functional outcomes and oncological benefits of this procedure.

Journal of Medical Case Reports, Jan 11, 2011

Introduction: Ductal adenocarcinoma is a rare variety of the common acinar adenocarcinoma. It usu... more Introduction: Ductal adenocarcinoma is a rare variety of the common acinar adenocarcinoma. It usually presents with refractory symptoms, and during cystoscopy, it is seen as an exophytic lesion at the area of the verumontanum. Case presentation: An 82-year-old Caucasian man was diagnosed with ductal adenocarcinoma of the prostate after undergoing transurethral resection of the prostate for urinary retention. Immunohistochemistry confirmed the nature of the tumor. The patient was treated with triptorelin, 3.75 mg once/month, and bicalutamide, 50 mg 1 × 1. The serum prostate-specific antigen at three, six and 12 months after transurethral resection of the prostate was 0.1 ng/ml. The patient remains asymptomatic, and he entered a six-month follow-up protocol. Conclusion: Ductal adenocarcinoma often involves the central ducts of the gland and may present as an exophytic papillary lesion in the prostatic urethra. This is why it usually presents with refractory symptoms. The outcome for men with prostatic ductal adenocarcinoma is, in most studies, worse than the outcome for men with prostatic acinar adenocarcinoma. Aggressive management is indicated, even with low-volume metastatic disease.

PubMed, Jun 1, 2011

A 92 year-old male patient was submitted for an elective right nephrectomy for kidney adenocarcin... more A 92 year-old male patient was submitted for an elective right nephrectomy for kidney adenocarcinoma. Postoperatively, a three-day hospitalization in the ICU was required during which ampicillin/sulbactam was prophylactically administrated. From the 7 to the 9 postoperative day, he developed extensive abdominal distention, diffuse abdominal pain, diminished bowel sounds, fever (> 38.9°C), elevated leukocytosis (WBC 46,200 cells/μL), signs and symptoms compatible with systemic toxicity (hypotension and tachycardia), but no diarrhea. Plain Abdominal X-ray disclosed a toxic megacolon (transverse colon diameter > 10 cm) and absence of air in the rectal lumen, without radiological signs of obstructive ileus or volvulus. Colonoscopy with minimal gas insufflation, showed an inflamed and edematous mucosa with numerous discrete raised nodular lesions covered with yellow exudates up to the splenic flexure in a dilated and non-peristaltic bowel (Fig. 1). Stool cultures were positive for clostridium difficile. Based on the above, the diagnosis of fulminant colitis was made. Since intracolonic administration of vancomycin was considered risky, the patient was started on intravenous administration of 500 mg metronidazole three times daily and oral administration of 500 mg vancomycin four times daily. A subtotal colectomy with ileostomy on an emergency basis was recommended to the patient’s relatives, but they declined. Although the patient’s general condition improved over two days, haemodialysis sessions were required and he finally died on the 16 postoperative day. Clostridium difficile-associated disease, results in a broad spectrum of clinical manifestations ranging from mild gastrointestinal complaints or mild diarrhea to lifethreatening pseudomembranous colitis, fulminant colitis, toxic megacolon with septic shock and death (1). Exposure to antibiotics (in order of frequency : clindamycin, ampicillin and/or amoxicillin and cephalo sporins) (2), exposure to Clostridium difficile (which typically occurs in hospitals) and host factors (the ability of the host’s immune system to produce protective antibodies against the toxins of Clostridium difficile) play an important role in reducing the severity of disease further preventing recurrences (3) and represent the three main factors which are involved in the pathogenesis of Clostridium difficile-associated disease. Fulminant Clostridium difficile colitis (FCDC) occurs in 3% of patients with Clostridium difficile infection (4). Although there is no specific definition for FCDC, in the majority of the patients the disease presents with severe abdominal pain, distention, dehydration, hypotension, oliguria, azotemia, high fever and marked leukocytosis (up to 40,000 white blood cells/mm3) (5). FCDC is more common in patients with malignant disease, renal failure, immunosuppression or on antiperistaltic agents. Patients with FCDC have a 57% 30-day mortality rate, a 49% inhospital mortality rate and a 38% 5-year survival rate if they survive longer than 30 days after hospital discharge (6). However, the diagnosis of FCDC remains difficult, while diarrhea is absent in 20% of the patients and these patients are at greatest risk for toxic megacolon development (7). Clinical criteria for diagnosing toxic megacolon are any 3 of the 4 following : (i) temperature greater than 38,6°C, (ii) heart rate greater than

International Urology and Nephrology, Mar 6, 2009

Introduction Significant decreases in tumour recurrence rates of up to 50% are reported after one... more Introduction Significant decreases in tumour recurrence rates of up to 50% are reported after one immediate postoperative instillation of chemotherapeutic drugs, such as epirubicin or mitomycin C. However, the extremely rare occurrence of complications related to perforation of the bladder can be detrimental. Perforation of the bladder seems to be iatrogenic (primary) or drug-induced (secondary). Materials and methods We present two cases of significant morbidity related to primary and secondary perforation of the bladder following two instillations of epirubicin. Results The patient with the primary perforation was managed conservatively, while the second was subjected to immediate surgical exploration. The two patients were finally released in good condition. Conclusions Complications concerning a primary perforation of the bladder and instillation of chemotherapeutic drugs can be easily avoided by recognising the perforation intraoperatively. However, we postulate that a delayed perforation of the bladder might occur due to the cytotoxic effect to the bladder tissue of the instilled drugs.

The Journal of Urology, Apr 1, 2019

cases. Age (p[0.011), Pathological Gleason (P<0.001) and Stage (p[0.010) were predictive of BCR. ... more cases. Age (p[0.011), Pathological Gleason (P<0.001) and Stage (p[0.010) were predictive of BCR. Adjuvant or Salvage Radiotherapy was required in 63 (13.7%) cases. Overall, there were 57 (12.4%) deaths; 10 (2.17%) died of prostate cancer with a median survival of 8.3yrs. At the last follow-up, 421 (91%) of patients were completely dry [no pads]. Artificial urinary sphincter or male sling were required in 6 (1.3%) cases. Seven (1.5%) had required dilatation of bladder neck stricture. 132 (28.6%) patients were able to have intercourse pre-and post-operatively without any treatments. 175 (37.9%) men were able to have penetrative intercourse with/without treatment. Five (1.1%) required penile prosthesis. CONCLUSIONS: In conclusion, RALP confers durable oncological outcomes beyond 10 years as prostate cancer specific (2.2%) and other-cause (10.2%) mortalities are relatively low. In this first study to also look at functional outcomes of RALP beyond 10 years, continence was excellent with around 9 in 10 (91%) men remaining completely dry. Around a third of men were continuing to have penetrative intercourse.

The Journal of Sexual Medicine, May 1, 2013

Erectile dysfunction has been widely investigated as the major factor responsible for sexual both... more Erectile dysfunction has been widely investigated as the major factor responsible for sexual bother in patients after radical prostatectomy (RP); painful orgasm (PO) is one element of this bother, but little is known about its prevalence and its effects on sexual health. This study aims to investigate the prevalence of PO and to identify potential risk factors. A total of 1,411 consecutive patients underwent open (radical retropubic prostatectomy) or robot-assisted laparoscopic RP between 2002 and 2006. The patients were asked to complete a study-specific questionnaire. Of a total of 145 questions, 5 dealt with the orgasmic characteristics. The questionnaire was also administered to a comparison group of 442 persons, matched for age and area of residency. The response rate was 91% (1,288 patients). A total of 143 (11%) patients reported PO. Among the 834 men being able to have an orgasm, the prevalence was 18% vs. 6% in the comparison group (relative risk [RR] 2.8, 95% confidence interval [CI] 1.7-4.5). When analyzed as independent variables, bilateral seminal vesicle (SV)-sparing approach (RR 2.33, 95% CI 1.0-5.3, P = 0.045) and age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;60 years were significantly related to the presence of PO (95% CI 0.5-0.9, P = 0.019). After adjustment for age, bilateral SV-sparing still remained a significant predictor for occurrence of PO. We found that PO occurs significantly more often in patients undergoing bilateral SV-sparing RP when compared with age-matched comparison population.

Urologic Oncology-seminars and Original Investigations, 2020

Purpose: Differences exist concerning when and how to perform lymph node dissection (LND) during ... more Purpose: Differences exist concerning when and how to perform lymph node dissection (LND) during radical prostatectomy due to lack of high-grade evidence to its safety and efficacy. We aimed to compare readmission rates between limited and extended LND during open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP). Materials and methods: We conducted a prospective trial of 3,706 eligible patients comparing ORP vs. RARP (LAPPRO). Six hundred and twenty-seven underwent concomitant LND. Data were retrieved for readmissions within 90 days from surgery from the Swedish Patient Registry. Causes for readmissions were classified according to the modified Clavien-Dindo classification system. We estimated risks for readmission stratified by type of LND and surgical approach. Results: We recorded 107 readmissions in 90 patients. The overall readmission rate was 14% (90/627). In the open group, extended LND had a higher, but not statistically significant readmission rate of 18% compared to 11% after limited LND (95%CI 0.87−3.01). In the robot-assisted group, readmissions after extended LND did not differ from limited LND (15% vs. 18%, 95%CI 0.49−1.61). RARP with limited LND showed a higher risk for any (RR 1.98, 95%CI [1.02−3.81]) as well as Clavien-Dindo grade 1 to 2 readmissions (RR 2.49, 95%CI [1.10−5.63]) compared to open approach with limited LND. Robot-assisted extended LND reduced the risk for Clavien-Dindo grade 3 to 5 complications leading to readmissions compared to the open approach by 59% (RR 0.41, 95%CI [0.19-0.87]). Conclusions: The risk for hospital readmission was similar when performing limited or extended LND during a radical prostatectomy. Robotassisted technique for performing extended LND may decrease the risk for severe complications.

European Urology, Oct 1, 2013

Background: Although open radical cystectomy (ORC) remains the gold standard of care for muscle-i... more Background: Although open radical cystectomy (ORC) remains the gold standard of care for muscle-invasive bladder cancer, robot-assisted radical cystectomy (RARC) continues to gain wider acceptance. In this article, we focus on the steps of RARC, describing our approach, which has been developed over the past 10 yr. Totally intracorporeal RARC aims to offer the benefits of a complete minimally invasive approach while replicating the oncologic outcomes of open surgery. Objective: We report our outcomes of a totally intracorporeal RARC procedure, describing step by step our technique and highlighting the variations on this standard template of nerve-sparing and female organ-preserving approaches in men and women. Design, setting, and participants: Between December 2003 and October 2012, a total of 113 patients (94 male and 19 female) underwent totally intracorporeal RARC. Surgical procedure: We performed RARC, extended pelvic lymph node dissection, and a totally intracorporeal urinary diversion (UD) in all patients. In the accompanying video, we focus on the standard template for RARC, also describing nerve-sparing and female organ-preserving approaches. Outcome measurements and statistical analysis: Complications and oncologic outcomes are reported, including overall survival (OS) and cancer-specific survival (CSS) using Kaplan-Meier analysis. Results and limitations: RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37-84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. On surgical pathology, 48% of patients had pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The mean number of lymph nodes removed was 21 (range: 0-57). Twenty percent of patients had lymph node-positive disease. Positive surgical margins occurred in six cases (5.3%). Median follow-up was 25 mo (range: 3-107). We recorded a total of 70 early complications (0-30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade !3. Thirty-six late complications (>30 d) were recorded in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade !3. One patient (0.9%) died within 90 days of operation from pulmonary embolism. Using Kaplan-Meier analysis, CSS was 81% at 3 yr and 67% at 5 yr. Conclusions: Our structured approach to RARC has enabled us to develop this complex service while maintaining patient outcomes and complication rates comparable with ORC series. Our results demonstrate acceptable oncologic outcomes and encouraging long-term CSS rates.

European Urology Supplements, Mar 1, 2013

Scandinavian journal of urology, Jan 2, 2019

Purpose: All types of surgery are associated with complications. The debate is ongoing whether ro... more Purpose: All types of surgery are associated with complications. The debate is ongoing whether robot-assisted radical prostatectomy can lower this risk compared to open surgery. The objective of the present study was to evaluate post-operative adverse events leading to readmissions, using clinical records to classify these adverse events systematically. Materials and methods: A prospective controlled trial of men who underwent robot-assisted laparoscopic (RALP) or retropubic radical prostatectomy (RRP) at 14 departments of Urology (LAPPRO) between 2008 and 2011. Data on all readmissions within 3 months of surgery were collected from the Patient registry, Swedish Board of Health and Welfare. For each readmission the highest Clavien-Dindo grade was listed. Results: A total of 4003 patients were included in the LAPPRO trial and, after applying exclusion criteria, 3706 patients remained for analyses. The results showed no statistically significant difference in the overall readmission rates (8.1 vs. 7.1%) or readmission due to major complications (Clavien-Dindo !3b, 1.7 vs. 1.9%) between RALP and RRP within 90 days after surgery. Patients subjected to lymphnode dissection (LND) had twice the risk for readmission as men not undergoing LND, irrespective RALP or RRP technique. Blood transfusion was significantly more frequent during and within 30 days of RRP surgery (16 vs. 4%). Abdominal symptoms were more common after RALP. Conclusions: There is a substantial risk for hospital readmission after prostate-cancer surgery, regardless of technique; although major complications are rare. Regardless of surgical technique, attention should be focused on specific types of complications.

European Urology, Nov 1, 2013

Background: Robot-assisted radical cystectomy (RARC) with totally intracorporeal neobladder diver... more Background: Robot-assisted radical cystectomy (RARC) with totally intracorporeal neobladder diversion is a complex procedure that has been reported with good outcomes in small series. Objective: To present complications and oncologic and functional outcomes of this procedure. Design, setting, and participants: Between 2003 and 2012 in a tertiary referral center, 70 patients were operated on by two experienced robotic surgeons. Data were collected prospectively and reviewed retrospectively. Intervention: RARC with totally intracorporeal modified Studer ileal neobladder formation. Outcome measurements and statistical analysis: The overall outcome of RARC with a totally intracorporeal neobladder was presented by assessing (1) surgical margins, (2) recurrence or cancer-specific death at 24 mo, (3) 30-d and 90-d complications graded according to the modified Clavien-Dindo system, (4) daytime and nighttime continence (no or one pad per day) at 6 and 12 mo, and (5) satisfactory sexual activity or potency at 6 mo and 12 mo. Survival rates were estimated by Kaplan-Meier plots. Results and limitations: Median follow-up of the cohort was 30.3 mo (interquartile range: 12.7-35.6). We recorded negative margins in 69 of 70 patients (98.6%). Clavien 3-5 complications occurred in 22 of 70 patients (31.4%) at 30 d and 13 of 70 (18.6%) at >30 d. At 90 d, the overall complication rate was 58.5%. Clavien <3 and Clavien !3 complications were recorded in 15 of 70 patients (21.4%) and 26 of 70 (37.1%), respectively. Kaplan-Meier estimates for recurrence-free, cancer-specific, and overall survival at 24 mo were 80.7%, 88.9%, and 88.9%, respectively. Daytime continence and satisfactory sexual function or potency at 12 mo ranged between 70% and 90% in both men and women. Limitations of this study include its retrospective design, selection bias due to the learning curve phase, and missing data. Conclusions: In this expert center for RARC, outcomes after RARC with totally intracorporeal neobladder diversion appear satisfactory and in line with contemporary open series.

World Journal of Urology, Mar 20, 2021

To evaluate urinary continence (UC) recovery and oncological outcomes in different risk-groups af... more To evaluate urinary continence (UC) recovery and oncological outcomes in different risk-groups after robot-assisted radical prostatectomy (RALP) and open retropubic radical prostatectomy (RRP). We analysed 2650 men with prostate cancer from seven open (n = 805) and seven robotic (n = 1845) Swedish centres between 2008 and 2011 in a prospective non-randomised trial, LAPPRO. UC recovery was defined as change of pads less than once in 24 h. Information was collected through validated questionnaires. Rate of positive surgical margins (PSM) and biochemical recurrence (BCR), defined as prostate-specific antigen (PSA) > 0.25 mg/ml, were recorded. We stratified patients into two risk groups (low-intermediate and high risk) based on the D’Amico risk classification system. Among men with high-risk prostate cancer, we found significantly higher rates of UC recovery up to 24 months after RRP compared to RALP (66.1% vs 60.5%) RR 0.85 (CI 95% 0.73–0.99) while PSM was more frequent after RRP compared to RALP (46.8% vs 23.5%) RR 1.56 (CI 95% 1.10–2.21). In the same group no significant difference was seen in BCR. Overall, however, BCR was significantly more common after RRP compared to RALP at 24 months (9.8% vs 6.6%) RR 1.43 (Cl 95% 1.08–1.89). The limitations of this study are its non-randomized design and the relatively short time of follow-up. Our study indicates that men with high-risk tumour operated with open surgery had better urinary continence recovery but with a higher risk of PSM than after robotic-assisted laparoscopic surgery. No significant difference was seen in biochemical recurrence. ISRCTN06393679.

European Urology Supplements, Sep 1, 2014

Figure 2 failed to achieve competence in challenging critical steps, such as vesico-urethral anas... more Figure 2 failed to achieve competence in challenging critical steps, such as vesico-urethral anastomosis in the initial phase of the study. Conclusions: RARP Assessment Score based on HFMEA methodology identified critical hazardous steps specific to RARP and was used to assess and evaluate surgeons while performing RARP.