[Urinary diversion in old patients (80+ years)]. / Harnableitung beim alten Patienten (80+).

With increasing life expectancy there is also an increased need for the management of older (≥ 80 years) patients with the diagnosis of muscle-invasive bladder cancer. Radical cystectomy with urinary diversion is the state of the art treatment (with neoadjuvant chemotherapy, as long as the patient is fit enough). Choosing the best urinary diversion with respect to morbidity compared to functionality and quality of life remains a challenge in these patients. Physical age alone is not decisive for making a decision. A thorough preoperative assessment of medical features, physical and cognitive impairments is more important. Older patients are generally provided with an ileal conduit as an incontinent urinary diversion, as the intervention involves reduced operating times and complexity compared to continent urinary diversions; however, in the case of good health status with an adequate life expectancy and sufficient compliance, continent diversions may be considered even in aged candidates. In the case of multimorbid patients with a high perioperative risk, ureterostomy with permanent ureteric stents is an important alternative. Most importantly, a thorough preoperative counselling enables patients to reach an informed decision.

[Safety and efficacy of en bloc vs. conventional transurethral resection of bladder tumors: a meta-analysis and systematic review]. / Sicherheit und Effizienz der en bloc vs. konventionellen transurethralen Resektion von Blasentumoren: eine Metaanalyse und systematic Review.

BACKGROUND: En bloc tumor resection of bladder tumors (ERBT) is a novel alternative procedure to conventional resection of bladder tumor (cTURBT), which might help to address common problems of the standard method, such as inadequate detrusor muscle in specimens, high re-resection rates and high recurrence rates. OBJECTIVE: To analyze current data on ERBT in efficacy and safety compared to cTURBT. DATA SOURCES: PubMed. STUDY SELECTION: Two independent authors identified trials based on keywords and inclusion criteria. A third author was consulted in case of discrepancies. Screening keywords: ERBT, en bloc transurethral resection of bladder tumor, TURBT en bloc. A meta-analysis of 13 studies was performed. The effect size was estimated based on odds ratios and mean differences including their corresponding two-sided 95% confidence intervals. DATA SYNTHESIS: The analyzed studies comprised a homogenous collective in terms of tumor size, tumor multiplicity and tumor stage. Operation time did not significantly differ between the methods. Differences were observed in hospitalization and catheterization time in favor of ERBT. Reported complications did not show clear differences. There was significantly more detrusor muscle in the specimens in the ERBT group. No significant differences were found in recurrence up to 2 years of follow-up. CONCLUSION: ERBT is a safe alternative to conventional TURBT with promising features regarding effective resection of detrusor muscle. More standardized data on recurrence rates, different resection modalities and resection margin results are needed.

[Management of geriatric patients with benign prostatic hyperplasia]. / Das Management geriatrischer Patienten mit benignem Prostatasyndrom.

Multimorbid older men are increasingly more common in daily practice and present a challenge because they are often affected by lower urinary tract symptoms (LUTS) and age-associated benign prostatic hyperplasia (BPH). In order to identify possible risks in diagnostics, therapy and counselling at an early stage, screening for functional deficits or risk factors with standardized procedures is helpful. An initial screening with subsequent assessment of everyday skills using the Barthel Index, Timed up & Go Test, and a cognitive test are recommended. If frailty syndrome is detected, it should be taken into account during the pre-, peri-, and postoperative management, as it may indicate increased morbidity and mortality. Noninvasive methods for reducing the prostate volume without anesthesia can be a therapy option in older multimorbid patients, and with individual planning and consideration of risk factors, up to 70% of individuals become symptom-free. However, there is currently no gold standard for this vulnerable patient group. Number of medications and concomitant diseases and higher need for help are per se risk factors for unsatisfactory results after transurethral resection of the prostate (TURP) or laser vaporization. With drug therapy, concomitant medications and their interactions, especially in the cytochrome system, an existing multimorbidity and adherence to therapy must be taken into account. Combination therapies may complement each other and may bridge the time until surgery. Minimally invasive methods that can be performed without general anesthesia are suitable for geriatric patients, especially those with recurrent retention. Studies with the Rezüm® system (NxThera Inc., Maple Grove, MN, USA) and UroLift® (NeoTract Inc., Pleasanton, CA, USA) show that about 70% of patients can be relieved from the permanent catheter.

[Endoscopic enucleation of the prostate]. / Endoskopische Enukleation der Prostata.

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

[Urological infections and antibiotic management in geriatric patients]. / Urologische Infektionen und Antibiotikamanagement bei geriatrischen Patienten.

Both the demographic shift and progress in medicine are resulting in an increasingly longer life expectancy. It is presumed that a mean age of 90 years will be achieved within the next decade in many countries. Thus, geriatric medicine, which is committed to the specific needs of older, often frail and frequently comorbid patients, is becoming increasingly more important. The prevalence of infections of the genitourinary tract increases with age, simultaneously, a critical and conscious use of antibiotics is required in terms of antimicrobial treatment. The intention of the present review is to make the reader aware of the specific characteristics of urinary tract infections and asymptomatic bacteriuria in the older patient population in terms of epidemiology, spectrum of pathogens and resistance as well as the indications for and performance of antimicrobial treatment.

[Immunostimulatory CpG oligodeoxynucleotides (CpG-ODN) in an orthotopic murine transitional cell carcinoma (TCC) model. Effect on local cytokine expression]. / Immunstimulative CpG-Oligodeoxynukleotide (CpG-ODN) im orthotopen murinen Transitionalzellkarzinom (TCC)-Modell. Effekt auf die lokale Zytokinexpression.

CpG-oligodeoxynucleotides (CpG-ODN) are potent stimulators of the innate immune system. They promote a Th1-biased immune response with antineoplastic potential. We recently demonstrated antitumoral effects of CpG-ODN in murine transitional cell carcinoma (TCC) models. The purpose of the present work was to more precisely define the immunological nature of this immunotherapeutic approach to TCC.MB-49 TCC was established in female C57/Bl6 mice by intravesical tumor cell instillation after poly-L-lysine conditioning of the bladder (day 0) as described previously. Three groups of six mice were treated: intravesical instillation of 50 microl PBS on days 1, 3, 5, and 7 (group 1, untreated control); 10 nmol CpG 1668 on days 1, 3, 5, and 7 (group 2); and 10 nmol GpC 1668 on days 1, 3, 5, and 7 (group 3). Six native bladders served as no-treatment/no-tumor controls (group 4). Mice were sacrificed on day 11; bladders and draining lymph nodes were removed, and mRNA was prepared for quantitative real-time polymerase chain reaction. Samples were analyzed on a Bio-Rad iCycler for IL 10, TGF-beta, IL 12, and IFNgamma expression; threshold values were compared to beta-actin as housekeeping gene.Tumor take was 100%. Three animals in group 1 had to be sacrificed in advance due to rapid tumor progression. Relative cytokine expression was comparable in groups 1 and 4. IL-10, IL-12, TGF-beta, and IFNgamma were overexpressed in groups 2 and 3. CpG-ODN treatment of murine TCC results in overexpression of both classic Th1 cytokines (IL 12 and IFNgamma) and the Th2 marker IL 10. TGF-beta expression is increased as well. These phenomena are not induced by the growing TCC but by CpG-ODN therapy. They are accompanied by an objective clinical response, as we were able to show recently. Immunostimulatory DNA holds promise to be a novel therapeutic agent in TCC.

[German Association for Bladder Cancer Research]. / Deutscher Forschungsverbund Blasenkarzinom e.V.

The "German Association for Bladder Cancer Research" was founded in May 2008 by urologists, scientists, and pathologists. The purpose of this association is to concentrate research activities on a national level, to facilitate collaborations with an interdisciplinary background, and to define standard methodology for a higher quality of scientific results. Additionally, a national database for bladder cancer specimens will be initiated. The website http://www.forschungsverbund-blasenkarzinom.de will provide further information about the German Association for Bladder Cancer Research.

[Gender-specific characteristics and survival of renal cell carcinoma]. / Geschlechtsspezifische Charakteristika und Prognose des Nierenzellkarzinoms.

BACKGROUND: Renal cell carcinoma (RCC) occurs twice as often in men as in women; however, the influence of gender on stage, grade, subtype and prognosis has not been studied in detail. METHODS: This study included 780 patients treated by (partial) nephrectomy at our institution in Marburg between 1990 and 2005. The mean follow-up was 5.44 years. RESULTS: Of the 780 patients, 486 (62%) were men and 294 (38%) were women. Women were significantly older (mean, 65.3 vs. 62.2 years; p<0.001, t-test), presented at lower T stages (p=0.046, chi(2)) and suffered metastasis less frequently at diagnosis (p=0.026, chi(2)). In addition, women more frequently had clear cell tumours (85.2% vs. 78.3%) and less frequently papillary tumours (11.0% vs. 18.8%) than men (p=0.026, chi(2)). In contrast, men had an increased risk of death from RCC (HR 1.23, CI 0.92-1.63); Kaplan-Meier curves revealed a significant difference in tumour-specific survival between men and women (p=0.033, log rank; 5-year survival 74% vs. 83%). However, unlike tumour stage and tumour grade, gender could not be retained as a significant independent prognostic marker in multivariate analysis. CONCLUSION: In general, RCC in men is characterized by higher tumour stages and more frequent metastasis at diagnosis along with inferior tumour-specific survival. However, as gender failed to qualify as an independent prognostic marker for tumour-specific survival, delayed diagnosis due to insufficient routine medical check-up and/or a more aggressive tumour biology might be be a concurrent cause. Thorough regular medical check-ups for men, also with regard to RCC, are thus mandatory.

[Transitional cell carcinoma of the bladder. Evaluation of plasma levels of cellular fibronectin as a stage-dependent marker]. / Das Transitionalzellkarzinom der Harnblase. Evaluation von zellulärem Fibronektin im Plasma als stadienabhängiger Marker.

Up to now markers for transitional cell carcinoma of the bladder (TCC) are missing. Fibronectin (FN) seems to play a key role in progression and invasion of malignant tumors. The aim of this study was to assess the value of cellular FN (cFN), a more specific subform of produced FN, in different stages of TCC.cFN was determined using a highly sensitive immunoassay which we developed. Blood samples were taken of 45 patients with the first diagnosis of TCC before undergoing TUR-B and 6 patients with metastatic TCC before chemotherapy; 70 patients with nonmalignant urological disorders served as a control group.Patients with TCC showed significantly elevated cFN plasma levels compared to controls (p<0.05). Patients with muscle-invasive disease (n=15) showed significantly higher cFN plasma levels compared to the group with superficial TCC. Patients with metastatic TCC showed the highest, but not significantly elevated cFN plasma levels compared to patients with muscle-invasive TCC.The elevated cFN plasma levels in TCC underline the important role of cFN for tumor progression and its potential role as a marker for TCC. Upcoming investigations are necessary to prove the value of the potential marker cFN during follow-up and its impact as a prognostic factor for recurrence and progression of TCC.

[Follow-up of bladder cancer : The right examinations at the right time]. / Tumornachsorge des Harnblasenkarzinoms : Die richtigen Untersuchungen zum richtigen Zeitpunkt.

Schedules for the follow-up (FU) of bladder cancer patients are predominantly based on studies with low level of evidence and the resulting guidelines' recommendations that are often founded on expert consensus. FU of non-muscle invasive bladder cancer (NMIBC) includes cystoscopy and cytology as standard, and imaging modalities to a lower extent. FU of muscle-invasive bladder cancer (MIBC) depends primarily on the therapeutic modality chosen and on the stage of disease. In this scenario, FU is complemented by functional and quality of life related aspects. These apply even more for FU in palliative situations. Here, the individual focus is on examinations that might have a consequence in terms of survival and/or symptom relief.

[Extracorporeal shock wave lithotripsy]. / Extrakorporale Stoßwellenlithotripsie.

Interventional treatment of stones essentially consists of three treatment modalities. Extracorporeal shockwave lithotripsy (ESWL), in addition to uterorenoscopy (URS) and percutaneous nephrolitholapaxy (PCNL) is an essential treatment pillar and is the only noninvasive therapy option for the treatment of urinary stones. After a long period of ESWL being the leading choice in stone treatment, the number of SWL interventions diminished in recent years in favor of the other two treatment modalities (URS and PCNL). This article describes the indications, surgical technique and management of complications of SWL.

[Cystitis emphysematosa--a case report]. / Emphysematöse Zystitis : Ein Fallbericht.

We present a rare case of cystitis emphysematosa in an 85-year-old female patient in whom the typical risk factors were present: diabetes of long standing, neurogenic bladder and urinary infection with E.coli. Thanks to early diagnosis by cystoscopy and abdominal CT, after antibiotic treatment, appropriate insulin therapy and continuous bladder drainage the course was uneventful. The patient was fit to leave hospital after 14 days.

[Ureterorenoscopy]. / Ureterorenoskopie.

Ureterorenoscopy (URS) is a minimally invasive treatment option for removal of kidney stones, which has gained importance in this field over the past two decades. This technique has replaced extracorporeal shock wave lithotripsy (ESWL) stone surgery for many indications. It is also particularly important in the diagnostics and treatment for tumors of the upper urinary tract. This article describes the indications, surgical technique and management of complications of URS.

[Surgical positioning techniques in urology : Tips and tricks]. / Lagerungstechniken in der Urologie : Tipps und Tricks.

Correct positioning of patients during preoperative preparations is essential for success of the intervention to avoid any positioning trauma and to provide the best access to the targeted structures. The appropriate positioning (and optimal performance) means that complications are avoided and also makes an essential contribution to the smooth course of the surgical intervention. A correct position is essential particularly in urology because the organs assigned to the discipline of urology are anatomically mostly difficult to reach. A further important function of the correct positioning technique is the avoidance of injuries to the patient. This article summarizes the most common positioning techniques in urological interventions with special emphasis on the explanation of practical advice, helpful tips and possible complications that can enable even junior surgeons to correctly perform the appropriate positioning technique.

Second-line strategies for metastatic renal cell carcinoma: classics and novel approaches.

OBJECTIVES: Renal cell carcinoma is an aggressive malignancy with a high propensity for both early and metachronous regional and distant metastasis. While surgical resection is the mainstay of therapy for patients with localized disease, the prognosis for patients with distant metastasis is poor with a 5-year survival rate of less than 10%. Response rates to first-line immunotherapy or immunochemotherapy range from 10-35%; responses achieved are predominantly partial remissions of short duration. Until today, there is no standard therapeutic procedure for the growing number of patients who relapse following first-line therapy and desire further active treatment. MATERIALS AND METHODS: This article reviews classic and recent publications about second- and third-line approaches, their potential efficacy and toxicity. RESULTS: Several novel approaches have raised well-founded hope. Especially the application of monoclonal antibodies targeting VEGF signalling as well as different receptor tyrosine kinase inhibitors have the potential to change the face of second-line treatment of patients with metastatic RCC. Both groups of agents are focused in current phase III trials, either as mono- and/or combination therapy. CONCLUSIONS: Until today, second-line treatment of patients with metastatic RCC progressing under therapy with biological response modifiers remains an unresolved issue. The results of ongoing clinical trials evaluating novel targeted approaches can be expected with suspense.

[Second-line thalidomide/IL-2 therapy in metastatic kidney cancer--results of a pilot study]. / Thalidomid/Interleukin-2 in der Second-line-Therapie des metastasierten Nierenzellkarzinoms--Ergebnisse einer Pilotstudie.

PURPOSE: On the basis of promising first-line data we have evaluated the safety and efficacy of a combination therapy comprising interleukin-2 (IL-2) and thalidomide in patients with metastatic renal cell carcinoma (RCC) refractory to both immuno- and chemotherapy. PATIENTS AND METHODS: 14 patients with progressive metastatic RCC, in whom prior immunochemotherapy had failed but who desired further active therapy, were enrolled in this study. Oral thalidomide was started at 200 mg/d and escalated after two days to 400 mg/d at week 0. IL-2 at 7 MIU/m (2) was given by subcutaneous injection, starting at week 1, days 1 to 5, weeks 1 to 4, with no IL-2 at weeks 5 and 6. The response was assessed every other therapy cycle. RESULTS: 12 patients were evaluable for response. There was no objective response; 4 patients showed stable disease for 21, 15, 13 and 9 months, respectively. Toxicities were predominantly grade 1 - 3 and included somnolence and constipation, as well as flu-like symptoms associated with IL-2. However, one patient developed serious constipation which led to a paralytic ileus and discontinuation of treatment. Another patient left the study after seven weeks due to increasing confusion. 11 patients required IL-2 dose reduction. Time on therapy ranged from 3 - 44 weeks (median, 19 weeks). Median overall survival was 22 months. Up to date, all patients have discontinued treatment. CONCLUSIONS: We conclude that outpatient administration of thalidomide/IL-2 is feasible in patients with heavily pretreated and progressive RCC who desire further active treatment. However, toxicity and costs are considerable and the clinical benefit is uncertain. Therefore thalidomide/IL-2 may not represent a promising therapeutic approach for this subgroup of patients.

[Operative technique for percutaneous nephrolithotomy]. / Operative Technik der perkutanen Steintherapie.

Percutaneous nephrolithotomy (PCNL) is a well-established minimally invasive treatment option for removal of kidney stones. This technique has now replaced open stone surgery for virtually all indications. This article describes the indications, the surgical technique and the complication management of PCNL.

[Therapy of low-grade nonmuscle-invasive bladder cancer]. / Therapie des nicht-muskelinvasiven Low-grade-Harnblasenkarzinoms.

Nonmuscle-invasive bladder cancer (NMIBC) comprises a very heterogeneous group of malignancies; the biological behavior of these tumors depends primarily on their grading. Low-grade NMIBC are characterized by a high propensity for recurrence but a very low risk for progression to muscle invasion or metastatic disease. Thus, the first line goal of diagnostic procedures and therapy is reliable visualization and complete resection of all foci. Cytology and other urine-based markers fail due to insufficient sensitivity. A second resection might be necessary only in selected intermediate risk cases; the positive effect of maintenance instillation protocols beyond a single postoperative instillation is questionable for the majority of patients. Risk stratification, e.g., according to the EORTC or EAU proposals, also makes sense in low grade NMIBC.

[Indications for nephron-sparing surgery. Analysis over a 13-year period in the context of changing guidelines]. / Indikationsstellung zur organerhaltenden Nierentumorchirurgie. Analyse eines 13-Jahres-Zeitraums vor dem Hintergrund sich wandelnder Leitlinien.

BACKGROUND: The indications for nephron-sparing surgery have been considerably extended by guideline recommendations in recent years. It remains unclear whether clinical practice still reflects these new guidelines. OBJECTIVE: In this retrospective, monocentric analysis at a tertiary referral center the indications for partial nephrectomy over a 13-year period were evaluated. METHODS: In a retrospective database analysis all cases of surgically treated renal masses from 2001 to 2013 were evaluated. Besides demographic, tumor-specific and perioperative variables the development of the surgical technique depending on the tumor stage was evaluated. RESULTS AND DISCUSSION: The proportion of nephron-sparing surgery cases increased from below 20 % in 2001 to 35 % in 2013 in the entire cohort. For stage T1a tumors, partial nephrectomy increased from approximately 50 % to over 90 % and for T1b tumors it rose from 10 % to 50 %. Logistic regression revealed stage 1 tumors to be predictive of partial nephrectomy over the complete evaluation period. Extending the indications for partial nephrectomy even to higher stages is under discussion but not yet supported by data from prospective, controlled studies.