Clinical nodal staging scores for prostate cancer: a proposal for preoperative risk assessment.

BACKGROUND: Pelvic lymph node dissection in patients undergoing radical prostatectomy for clinically localised prostate cancer is not without morbidity and its therapeutical benefit is still a matter of debate. The objective of this study was to develop a model that allows preoperative determination of the minimum number of lymph nodes needed to be removed at radical prostatectomy to ensure true nodal status. METHODS: We analysed data from 4770 patients treated with radical prostatectomy and pelvic lymph node dissection between 2000 and 2011 from eight academic centres. For external validation of our model, we used data from a cohort of 3595 patients who underwent an anatomically defined extended pelvic lymph node dissection. We estimated the sensitivity of pathological nodal staging using a beta-binomial model and developed a novel clinical (preoperative) nodal staging score (cNSS), which represents the probability that a patient has lymph node metastasis as a function of the number of examined nodes. RESULTS: In the development and validation cohorts, the probability of missing a positive lymph node decreases with increase in the number of nodes examined. A 90% cNSS can be achieved in the development and validation cohorts by examining 1-6 nodes in cT1 and 6-8 nodes in cT2 tumours. With 11 nodes examined, patients in the development and validation cohorts achieved a cNSS of 90% and 80% with cT3 tumours, respectively. CONCLUSIONS: Pelvic lymph node dissection is the only reliable technique to ensure accurate nodal staging in patients treated with radical prostatectomy for clinically localised prostate cancer. The minimum number of examined lymph nodes needed for accurate nodal staging may be predictable, being strongly dependent on prostate cancer characteristics at diagnosis.

[Retroperitoneal endometriosis : When a rare form of endometriosis becomes a urological disease]. / Retroperitoneale Endometriose : Wenn eine seltene Form der Endometriose zur urologischen Erkrankung wird.

BACKGROUND: Retroperitoneal endometriosis is a common benign disease, which requires an interdisciplinary approach. In the clinical practice diagnosis is often delayed for years after onset of the unspecific symptoms so that increased awareness is necessary for detection of the presence of the disease. OBJECTIVE: This article provides a description of the disease including the symptoms and pathogenesis, an introduction to the complexity of diagnostic investigations and the current therapy recommendations. MATERIAL AND METHODS: Comparison of current therapy recommendations according to the guidelines under consideration of individual studies and background research. Assessment of studies and the accompanying interpretations with the intention of presenting an introduction to the topic with therapy recommendations. RESULTS: From a urological point of view retroperitoneal endometriosis is a benign disease affecting the ureters and urinary bladder. Involvement of the ureters leading to hydronephrosis caused by ureteral compression represents an absolute indication for therapy. Recurrent macrohematuria can also necessitate treatment. Treatment includes surgical excision of the focal point of endometriosis as the first line therapy. Various operative procedures and access routes are available but when possible a minimally invasive procedure should be used. A second line drug therapy is also possible. CONCLUSION: Surgical excision of a clinically significant focus of endometriosis is the gold standard for therapy. This procedure should take place in a specialized center within an interdisciplinary consensus. Due to the fact that endometriosis is primarily a benign disease, medical clarification for the patient concerning the benefits and risks of therapy is absolutely necessary. An individual therapy concept under consideration of factors, such as the specific clinical relevance and psychological stress is recommended and in close cooperation with the patient.

[Randomized controlled trials terminated prematurely: beneficial therapy effects]. / Vorzeitiger Abbruch randomisierter kontrollierter Studien : Vorteilsbedingter Therapieeffekt.

Randomized controlled trials (RCTs) stopped prematurely for beneficial therapy effects are becoming increasingly more prevalent in the urological literature and often receive great attention in the public and medical media. Urologists who practice evidence-based medicine should be aware of the potential bias and the different reasons why and how early termination of RCTs can and will affect the results. This review provides insights into the challenges clinical urologists face by interpreting the results of prematurely terminated RCTs.

[Urinary diversion and colon: transverse conduit and transverse pouch]. / Harnableitung und Dickdarm : Das Transversumconduit und der Transversumpouch.

In the vast majority of cases the terminal ileum is used for incontinent or continent bladder substitution. However, in irradiated patients the use of ileum segments or the ileocecal reservoir is associated with an increased risk of early and late complications. For this reason these patients should be treated with a transverse conduit or pouch as the method of choice if urinary diversion is indicated. The superior outcome of this high urinary diversion is due to the use of non-irradiated segments of the colon and ureter. The lack of experience in large bowel surgery by today's urologists should be compensated by training or referral of these high risk patients to a specialized center.

[Upper tract urothelial carcinoma. An update on clinical and pathological prognostic factors]. / Das Urothelkarzinom des oberen Harntraktes. Ein Update über klinische und pathologische prognostische Faktoren.

Upper urinary tract urothelial carcinoma (UTUC) is an uncommon but potentially lethal disease. Accurate risk stratification remains a challenge owing to the difficulty of clinical staging. Identification of risk factors may lead to individualized treatment and patient counselling and holds the potential to improve outcome. A non-systematic PubMed/Medline literature research was performed to identify and summarize clinical and pathological risk factors and urine-based markers which are associated with clinical outcome. Although knowledge of potential prognostic factors has improved over the last 5 years the overall evidence on UTUC risk factors remains limited and prospective, randomized trials are still missing. Radical nephroureterectomy is currently standard treatment for high-grade and muscle invasive UTUC. Several clinical and pathological factors (e.g. stage, grade, age, hydronephrosis, lymphovascular invasion, tumor necrosis and architecture, delay between diagnosis and surgery) were identified to be associated with outcome. Urinary cytology and fluorescence in-situ hybridization are the most commonly used urinary markers. Prospective randomized controlled trials are urgently needed to identify new risk factors and assess the efficacy. The incorporation of such prognosticators into multivariable prediction models may help to guide decision-making with regard to type of treatment, performance of lymphadenectomy and consideration of neoadjuvant or adjuvant systemic therapy.