Symptomatic and quality of life response to tolterodine in subgroups of men with overactive bladder symptoms and presumed non-obstructive benign prostatic hyperplasia.

OBJECTIVES: To investigate the symptomatic and quality of life (QoL) response to treatment with tolterodine extended release (ER) in subgroups of male patients with Overactive Bladder Syndrome (OAB) and LUTS suggestive of non-obstructive benign prostatic hyperplasia (BPH) according to age, symptom severity, diabetes mellitus status, and concomitant treatment for LUTS. METHODS: Patients treated with tolterodine ER 4 mg/day for OAB symptoms, alone or added to unsuccessful alpha-blocker treatment of > or =6 weeks duration, and presumed non-obstructive BPH (Q (max) > or = 15 ml/s) were observed for 12 weeks in a non-interventional study. Patients completed the International Prostate Symptom Score (IPSS) and Overactive Bladder Questionnaire (OAB-q) at baseline and after 12 weeks. RESULTS: 52.4% of 741 patients were aged < or =65 years; 4, 64, and 32% had mild, moderate, and severe symptoms, respectively, according to IPSS; 14% had diabetes mellitus, and in 42% tolterodine was added to alpha blockers. In the various subgroups, mean IPSS total scores improved by 2.8-11.1 points, IPSS QoL scores by 1.8-2.4 points, and all OAB-q subscores by more than 14 points. Only IPSS and OAB-q baseline scores had a relevant impact on changes during treatment, benefits were greatest in patients with more severe symptoms and bother. CONCLUSIONS: In men with symptoms of OAB and LUTS suggestive of non-obstructive BPH of all IPSS severity classes, aged < or =65 years or above, with or without concomitant diabetes or alpha-blockers, symptoms and QoL improved markedly during treatment with tolterodine ER.

[Use of synthetic slings and mesh implants in the treatment of female stress urinary incontinence and prolapse : Statement of the Working Group on Urological Functional Diagnostics and Female Urology of the Academy of the German Society of Urology]. / Einsatz von synthetischen Band- und Netzimplantaten bei der Behandlung von Belastungsinkontinenz und Descensus genitalis der Frau : Stellungnahme des Arbeitskreises Urologische Funktionsdiagnostik und Urologie der Frau der Akademie der Deutschen Gesellschaft für Urologie.

Due to a safety alert issued by the US Food and Drug Administration (FDA) in 2011 for transvaginal mesh implants to treat female prolapse as a result of numerous reports of complications such as infection, chronic pain, dyspareunia, vaginal erosion, shrinkage and erosion into other organs nearly all industrial products have been withdrawn from the market in the meantime. The United Kingdom, Australia, and New Zealand extended warnings and prohibitions even on the implantation of midurethral slings (TVT, TOT). In view of these current international controversies regarding the use of implanted materials for the treatment of stress incontinence and prolapse and the lack of clear guidelines for the use of biomaterials, the opinion of the Working Group on Urological Functional Diagnostics and Female Urology should provide clarity. The Opinion is based on the SCENIHR Report of the "European Commission's Scientific Committee on Emerging and Newly Identified Health Risks", the "Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence" and in compliance with relevant EAU and national guidelines and the opinion of the Association for Urogynaecology and Plastic Pelvic Floor Reconstruction (AGUB eV). In addition, recommendations are given for the future handling of implants of slings and meshes for the treatment of stress incontinence and prolapse from a urologic viewpoint.

[Fake News BPH - what is really true!] / Hartnäckige Mythen zum Thema BPS ­ und was davon wirklich stimmt!

BACKGROUND: Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) is the fourth most common and the fifth most costly disease in men aged 50 years or older. Despite the high prevalence of LUTS/BPH in clinical practice and evidence-based guideline recommendations, there are still plenty of misconceptions on the terminology and pathophysiology of the disease, leading to false assumptions and malpractice. OBJECTIVES: Listing of commonly used false assumptions and clarification of the correct terminology and pathophysiology. MATERIALS AND METHODS: Critical reflection of 12 selected fake news based on PubMed search. RESULTS: Average prostate weight in healthy men is 20 g but varies between 8-40 g. The BPH-disease does not progress in stages; therefore, the BPH-classifications according Alken or Vahlensieck should not be used anymore. There is only a weak and inconsistent relationship between bladder outlet obstruction (BOO) and prostate size, diverticula/pseudo-diverticula, postvoid residual, urinary retention or renal insufficiency, which is too unreliable for BOO-diagnosis in the individual patient. Urethro-cystoscopy with grading of the degrees of occlusion of the prostatic urethra and bladder trabeculation is insufficient for BOO-diagnosis. There is no clinically relevant reduction of BOO with licensed BPH-drugs and no convincing data that prostate resection (TURP) has to be complete until the surgical capsule in order to obtain optimal results. CONCLUSIONS: The reasons for the persistent use of wrong terminology and pathophysiology are diverse. One reason is lack of implementation of evidence-based guidelines into clinical practice due to lack of knowledge, individual beliefs, costs, availability and reimbursement policies. Another reason is the increasing focus on oncology, coupled with underrepresented education and training on BPH.

[Combined treatment of BPS with tamsulosin and finasteride : Literature review and prescription data]. / Kombinationsbehandlung des BPS mit Tamsulosin und Finasterid : Literaturübersicht und Verordnungsdaten.

Combined therapy of benign prostatic syndrome (BPS) with α1-blockers and 5α-reductase (5AR)-inhibitors is recommended according to two leading studies on doxazosin/finasteride and tamsulosin/dutasteride for all 10 in Germany possible combinations (five α1-blockers and two 5AR inhibitors). Because tamsulosin and finasteride predominate in the treatment of BPS in Germany, the role of the combination tamsulosin/finasteride and its scientific basis from clinical studies has been investigated. A pharmacoepidemiological extrapolation from receipts of pharmacy data centres showed a strong increase of the combination tamsulosin/finasteride since 2003. As a free combination, tamsulosin/finasteride beside the fixed combination tamsulosin/dutasteride accounts to about 50% of all α1-blocker/5AR-inhibitor combinations today. Clinical studies on tamsulosin/finasteride have been published including controlled studies of the combination and both monotherapies. The results of improvement of lower urinary tract symptoms (LUTS), maximum urinary flow rate (Qmax), prostate volume (PV) and prostate-specific antigen (PSA) as well as adverse events and drug safety are in agreement with the leading studies. However, results due to chance cannot be excluded because of deficiencies in study design. A reliable comparison of the risk of progression between tamsulosin/finasteride and both monotherapies is lacking completely. Because of the great coherence and continuous evaluation of available data of all combinations, and with the established strong class effect of monotherapies, a continuation of the therapeutic practice with the combination tamsulosin/finasteride is possible.

[Terminology and Pathophysiology of Overactive Bladder (OAB)]. / Terminologie und Pathophysiologie der Überaktiven Harnblase (ÜAB).

In 2002, the International Continence Society defined the term overactive bladder (OAB) as a symptom syndrome that is accompanied by urgency with or without urge incontinence, frequency and nocturia. A proven urinary tract infection or other obvious pathologies must be excluded.The pathophysiology of OAB has not been clarified in detail and is the subject of ongoing research, so partially overlapping hypotheses exist. The urothelium-based hypothesis suggests functional changes of urothelial receptors as well as functional changes regarding the sensitivity and coupling of the suburothelial myofibroblasts, which ultimately lead to increasing activity of afferent signals and urgency. The myogenic hypothesis is based on the assumption that unstable detrusor contractions may be triggered by changes in their excitability and coupling with other myocytes or myofibroblasts. Unstable detrusor contractions generate increased afferent activity followed by symptoms of overactive bladder. The hypothesis of abnormal processing of afferent signals assumes that damage to central inhibitory pathways and/or sensitisation of afferent nerves lead to the activation of the micturition reflex, which, in turn, induces unstable detrusor contractions. In addition, hormonal and psychological influences are discussed.

[S2e guideline of the German urologists: Conservative and pharmacologic treatment of benign prostatic hyperplasia]. / S2e-Leitlinie der Deutschen Urologen : Konservative und medikamentöse Therapie des benignen Prostatasyndroms.

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the conservative and pharmacological treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding watchful waiting, behavioral therapy, phytotherapy and pharmacological mono- and combination therapy. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

[S2e guideline of the German urologists: Instrumental treatment of benign prostatic hyperplasia]. / S2e-Leitlinie der Deutschen Urologen : Instrumentelle Therapie des benignen Prostatasyndroms.

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the instrumental treatment of the lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding open and transurethral procedures (TUR-P, bipolar TUR-P, TUI-P, HE-TUMT, TUNA, and the different Laser techniques). Recommendations are also given concerning intraprostatic stents and injection therapies. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

[Drug therapy for benign prostatic hyperplasia. Systematic overview]. / Medikamentöse BPS-Therapie. Eine systematische Ubersicht.

5alpha-Reductase inhibitors and alpha(1)-receptor blockers are established options for symptomatic treatment of benign prostatic hyperplasia (BPH). Achieving maximum efficacy is contingent on correct dosage and requires careful patient selection in view of the substance class employed. All applicable preparations exert only a low-grade effect on prostatic obstruction. This condition should be excluded by appropriate urological examination before treatment is initiated. If the patient's distress is minor, refraining from drug therapy can be considered. Symptomatic patients with small prostate volume are suited for monotherapy with alpha(1)-receptor blockers and symptomatic patients with large prostate volume profit from combination therapy. When 5alpha-reductase inhibitors are used, BPH patients should be made aware of the findings from the Prostate Cancer Prevention Trial.

p53 overexpression as a prognostic factor for advanced stage bladder cancer.

Overexpression of the TP53 gene protein detected by immunohistochemistry appears to identify those patients with superficial bladder cancer at risk of the development of muscle invasive or metastatic disease. However, the role of p53 overexpression in patients with advanced or metastatic bladder cancer is not yet well established. In the present study, 44 specimens from 44 patients with advanced stage bladder tumours (T2-T4) undergoing radical cystectomy were investigated for different biological and clinical characteristics as possible prognostic factors: sex, age, depth of tumour infiltration, T-stage, histological grade, lymph node status, application of adjuvant systemic chemotherapy (MVAC), proliferative activity (staining for proliferating cell nuclear antigen (PCNA) by monoclonal antibody (PC10) as well as overexpression of the p53 oncoprotein (monoclonal antibody pAb 1801)). After a median follow-up of 22 months, 16 of the 23 patients (70%) with more than 40% of tumour cells stained positively for p53 (Group B) died from tumour progression compared with 7 of the 21 patients (33%) with less than 40% of tumour cells positive for p53. During univariate analysis, p53 overexpression (P = 0.008), staining for PCNA (> or = 80% of cells positive) (P = 0.01) and tumour stage (P = 0.01) were significant prognostic factors for survival, among which p53 overexpression (P = 0.023) as well as T-stage (P = 0.012) remained independent significant predictors during multivariate analysis. Prospective studies are needed to confirm the independent prognostic potential of p53 overexpression in patients with advanced bladder cancer. The availability of more refined prognostic factors should assist decision making regarding the value of more aggressive treatment options, such as adjuvant or neoadjuvant chemotherapy, for prognostically defined subgroups of patients.

Sacral electrical neuromodulation as an alternative treatment option for lower urinary tract dysfunction.

Temporary electrical stimulation using anal or vaginal electrodes and an external pulse generator has been a treatment modality for urinary urge incontinence for nearly three decades. In 1981 Tanagho and Schmidt introduced chronic electrical stimulation of the sacral spinal nerves using a permanently implanted sacral foramen electrode and a battery powered pulse generator for treatment of different kinds of lower urinary tract dysfunction, refractory to conservative treatment. At our department chronic unilateral electrical stimulation of the S3 sacral spinal nerve has been used for treatment of vesi-courethral dysfunction in 43 patients with a mean postoperative follow up of 43,6 months. Lasting symptomatic improvement by more than 50 % could be achieved in 13 of 18 patients with motor urge incontinence (72,2 %) and in 18 of the 21 patients with urinary retention (85,7 %). Implants offer a sustained therapeutic effect to treatment responders, which is not achieved by temporary neuromodulation. Chronic neuromodulation should be predominantly considered in patients with urinary retention. Furthermore in patients with motor urge incontinence, refusing temporary techniques or in those requiring too much effort to achieve a sustained clinical effect. Despite high initial costs chronic sacral neuromodulation is an economically reasonable treatment option in the long run, when comparing it to the more invasive remaining therapeutic alternatives.

Immunohistochemical detection of cathepsin-d expression in prostate-cancer.

Lysosomal proteases may be involved in facilitating cancer invasion and metastatic spread by degradation of basement membranes and intercellular matrix. Overexpression of cathepsin D, a lysosomal aspartyl protease, has been reported in different tumours and seems to constitute a prognostic factor for survival in patients with breast cancer. The current study investigates immunohistochemical staining using anti-cathepsin D monoclonal antobodies (M1G8) in prostate cancer specimens and tissue from patients with benign prostatic hyperplasia (BPH). Among 41 tumours expression of cathepsin D was observed in 14 of 26 (54%) low stage and grade tumours (T-1-2/G(1-2)) and in 12 of 15 (86%) high stage and grade tumours (T-3, G(3)). Cathepsin D positivity was found within the cytoplasm and at the surface of tumour cells localized in glandular structures and in single cells invading the prostatic stroma, while no staining was observed in normal prostatic tissue and in mesenchymal cells. Two of ten specimens from patients with benign prostatic hyperplasia showed a weakly positive staining reaction within glandular structures. The clinical course of localized prostate cancer appears to be highly variable and the different treatment strategies (radical prostatectomy, radiation therapy or surveillance) have come under debate. For the determination of the biological aggressiveness of prostate cancer in the individual patient easily available biological prognostic factors are needed. This report demonstrates overexpression of cathepsin D in prostate cancer specimens with increasing frequency in patients with tumours of high grade and stage. The usefulness of cathepsin D immunohistochemistry as a prognostic factor should be prospectively evaluated.

The MXI1 tumor suppressor gene is not mutated in primary prostate cancer.

For prostate cancer, allelic deletions from the long arm of chromosome 10 (#10q23-25), the locus of the putative tumor suppressor gene MXI1 (#10q24-25), have been identified as a frequently occurring genetic event. During the development of several human malignancies, the c-myc proto-oncogene has been identified to enhance cellular transformation, mitogenesis and cell proliferation. The MXI1 gene, belonging to the helix-loop-helix (bHLH) gene family, was demonstrated to display tumor suppressor function by antagonizing c-myc induced transcriptional activities. Due to the detection of point mutations in the retained alleles of four primary adenocarcinomas of the prostate, MXI1 gene alterations have been suggested to be involved in the development and/or the progression of prostate cancer. To evaluate the role of MXI1 gene alterations for the development of adenocarcinoma of the prostate, 42 primary prostate cancers of different stage (T1-4) and histological grade (G1-3) were investigated for alterations within exons 4 and 5 of the MXI1 gene (spanning 6 exons in total), encoding for the functional HLH-Zip domain, by RNA-SSCP analysis and direct PCR-DNA-sequencing following the microscopically guided tumor cell dissection from 5 microm fresh-frozen buffer-soaked tissue sections. Even by application of this highly elaborated technical approach, MXI1 gene alterations could not be deleted in any of the tumor specimens investigated. Therefore, a substantial involvement of MXI1 gene alterations in the development of prostate cancer appears unlikely. The newly identified putative tumor suppressor gene PTEN, located at #10q23, might be responsible for the frequently observed allelic deletions from #10q23-25 in prostate cancer.

Replantation of the complete external genitals.

Most cases of genital amputation represent an isolated penile amputation; the combined amputation of both penile and testes is reported very seldom. We describe a case of complete amputation of the external genitals with successful replantation and good functional outcome. The problem is analyzed with respect to operative strategy, ischemic periods, postoperative management, and psychiatric background. For the replantation of the testes, time frames are comparable to those for macroreplantations.

[Overactive bladder--treatment with antimuscarinic agents]. / Therapie der instabilen Blase-mit Antimuskarinika.

Today, urgency and urge incontinence are both defined under the topic overactive bladder (OAB) whereby pure urge syndrome (pollakisuria, nocturia, and urgency) can easily lead to urge incontinence. Antimuscarinics still constitute the domain of treatment for overactive bladder. The pharmacological effect of modern substances consists of M2 or M3 muscarinic receptor blockade. This blockade prevents acetylcholine from connecting to these receptors and thus leads to a weakness or prevention of the detrusor muscle contraction. These groups of drugs are defined as muscarinic receptor antagonists, antimuscarinics, or anticholinergics. In addition to the muscarinic receptors, some drugs directly block the calcium channels in the cell membrane (calcium antagonists) which are classified as drugs with mixed effect. The presented paper gives an overview about the existing data on drugs approved in Germany whose clinical effect has been proven in randomized studies or are have stood the test of time in daily clinical practice.

[Drug therapy of benign prostatic hyperplasia syndrome with alpha 1-receptor blockers. Basic principles and clinical results]. / Medikamentöse Therapie des benignen Prostatasyndroms mit alpha 1-Rezeptorblockern. Grundlagen und klinische Ergebnisse.

This article reviews the structure and function of the sympathetic nervous system controlling the myogenic tone of the bladder outlet. Therefore, the sympathetic nervous system is partially responsible for urinary outflow resistance. The alpha 1-adrenoceptor antagonists alfuzosin, doxazosin, tamsulosin, or terazosin are able to reduce bladder outflow resistance, which leads to significant relief of LUTS (20-65%) and improvement of urinary flow (1-4.3 ml/s) in patients with symptomatic BPH. Alpha 1-blocker treatment works irrespective of the severity of symptoms, degree of subvesical obstruction, or prostate size. A significant reduction of residual urine was observed only occasionally, but at least alfuzosin is able to reduce the incidence of acute urinary retention. This article presents the results of 39 randomized, placebo-controlled trials with 14,924 patients as well as trials with alpha 1-blockers and plant extracts or finasteride. The results of these trials indicate that all alpha 1-blockers are equally effective. However, tolerability of alfuzosin or tamsulosin is superior to doxazosin or terazosin. Furthermore, treatment of hypertension with doxazosin or terazosin is no longer recommended due to the increased frequency of cardiovascular side effects seen in the ALLHAT Study. As alpha 1-blockers can relieve symptoms and improve urinary flow more effectively than plant extracts or finasteride, alpha 1-blockers are the treatment of first choice in patients with symptomatic BPH without or with a minor degree of subvesical obstruction.

[Thermotherapy of benign prostatic hyperplasia]. / Thermotherapie der benignen Prostatahyperplasie.

Transurethral microwave thermotherapy (TUMT) differs from hyperthermia in the higher intraprostatic temperatures reached and in the irreversible damage it causes to intraprostatic tissue. Both subjective symptoms and objective data, such as peak flow and residual urine, are influenced differently by TUMT and by sham treatment. As expected, no improvement of the objective data was documented with TUMT, in contrast to transurethral resection of the prostate (TURP), whereas the improvement in subjective symptoms was comparable. The complication rate in terms of morbidity is clearly lower with TUMT than with TURP. TUMT can be performed as an outpatient procedure without a general anaesthetic. TUMT had a specific effect on outflow obstruction, but it was less pronounced than that achieved with TURP. Therefore, TUMT is indicated for patients with typical symptoms of BPH and a mild mechanical obstruction. In this patient group TUMT seems to be the optimal treatment, whereas TURP would constitute "overtreatment" owing to its higher complication rate and the unnecessary tissue resection. At this stage of BPH, TURP is justifiable only with reservations; it should be reserved for BPH with moderate and severe mechanical obstruction.

[Percutaneous bladder neck suspension with osseous fixation. Surgical technique and initial results in 26 patients]. / Perkutane Blasenhalssuspension mit ossärer Verankerung. OP-Technik und erste Ergebnisse bei 26 Patientinnen.

A modification of percutaneous needle suspension using a bone anchor system for fixation of the suture to the pubic bone is presented. After a follow-up of 3-11 months (mean 6,8) the postoperative success-rate in 26 patients is 73.1% (n = 19). A removal of bone anchor and suture was necessary in 2 patients because of bacterial infection or soft tissue granuloma. We can not reinforce the very optimistic results of the first reports published in the recent years. Therefore it is still questionable whether percutaneous needle bladder neck suspension should be a first line procedure for the treatment of female urinary stress incontinence.

[Effect of biological prognostic factors on therapy of non-seminomatous stage I testicular tumors--an assessment of the current status]. / Einfluss biologischer Prognose-faktoren auf die Therapie nicht-seminomatöser Hodentumoren im klinischen Stadium I--eine Standortbestimmung.

At present patients in whom a testicular germ cell tumour in clinical stage I is diagnosed have a long-term survival rate of 98%. For non-seminomatous germ cell tumours in this stage three different treatment options are available: primary retroperitoneal lymphadenectomy (PRLA), the wait-and-see strategy, and primary adjuvant systemic chemotherapy. These therapeutic approaches do not obviously differ in the long-term survival rate of the patients. Abdominal CT scans yield false-negative results in 20-30% of patients with occult metastases. The identification of certain histological characteristics within the primary tumour (vascular and/or lymphatic invasion, presence of embryonal carcinoma, absence of yolk sac elements) allows stratification of patients into groups at high and low risk for tumour progression and/or the presence of retroperitoneal lymph node metastases. The determination of biological and genetic characteristics of the primary tumour in addition to classic histological parameters, does not actually seem to reveal any further prognostic information relating to the biological behaviour of the individual tumour. Therefore, with regard to the outcome of prospective and retrospective MRC studies, patients should be stratified according to the Freedman score into groups at high and at low risk of tumour progression and consequently undergo an aggressive (retroperitoneal lymphadenectomy/systemic chemotherapy) or less aggressive (wait-and-see) treatment adjusted to the aggressiveness of the individual tumour. Prospective studies should be performed to find whether biological characteristics of the primary tumour might reveal any additional prognostic information superior to that yielded by histological parameters and possibly allow an even more subtle classification of the patients into high- and low-risk groups.

[Value of the proliferation status (PCNA) and p53 immunohistochemistry as a prognostic factor for the clinical course of superficial cancer of the urinary bladder]. / Wertigkeit von Proliferationsstatus (PCNA) und p53- Immunhistochemie als Prognosefaktor für den klinischen Verlauf superfizieller Harnblasenkarzinome.

Although patients with superficial bladder cancer (Ta, T1) have a generally good prognosis, those of them who have tumours invading muscle or metastatic disease will have a poor clinical prognosis. In the current study, 41 patients undergoing complete transurethral resection for superficial transitional cell cancer of the bladder were investigated for different clinical and biological characteristics as possible prognostic factors: age, sex, previous instillation therapy, immunohistochemical determination of mutational inactivation of p53 tumour suppressor gene (monoclonal antibody pAb 1801) and proliferation rate determined immunohistochemically by staining for PCNA (proliferating cell nuclear antigen; monoclonal antibody PC 10). After a median follow-up of 54 months 7 of 8 patients (87.5%) with more than 20% of cells positive for p53 had disease recurrence, as against only 1 of 33 patients (3%) negative for p53 detection (P < 0.01; Chi-square test). During univariate analysis histological grade (G1 vs G2; P = 0.007), positivity for PCNA (> 60% of cells; P = 0.003) and positivity for p53 (P = 0.001) were significant prognostic factors for disease progression (log rank test), while during multivariate analysis only positivity for p53 was a significant predictor for relapse of bladder cancer (P = 0.0035; multivariate Cox regression analysis).

[Prognostic relevance of vena cava thrombosis in renal cell carcinoma]. / Prognostische Relevanz des Kavathrombus beim Nierenzellkarzinom.

The independent prognostic value of neoplastic extension of renal cell cancer (RCC) into the vena cava inferior has been the subject of several investigations reported to date. However, the use of vena cava thrombosis as an independent prognosticator of a patient's long-term survival is still debated. We have therefore correlated the clinical course of 53 patients with RCC and vena cava thrombosis with a control group consisting of 47 patients with renal cell tumors without vena cava thrombosis (follow-up: 1-154 months). The median long-term survival of patients with and without vena cava thrombosis was 32 and 35 months, respectively. Neither the propagation of the tumor into the vena cava (P = 0.391) nor the cranial extension of the thrombosis (P = 0.158)--even in case of propagation into the right atrium--could be identified as parameters of any prognostic value during univariate or multivariate statistical analysis.