[Urogeriatric thinking using the example of antiandrogen therapy for prostate cancer]. / Urogeriatrisches Denken am Beispiel der antiandrogenen Therapie des Prostatakarzinoms.

The geriatric patient is defined by an age of over 75 years and multimorbidity or by an age of over 80 years. These patients exhibit a particular vulnerability, which, in the incidence of side effects or complications, leads to a loss of autonomy. Treatment sequalae, once they have arisen, can no longer be compensated. It is important to recognize and document treatment requirements among geriatric patients with the help of screening instruments such as the Identification of Seniors at Risk (ISAR) and Geriatric 8 (G8) scores. If a treatment requirement is identified, oncologic treatment should not be commenced uncritically but rather a focus placed on identification of functional deficits relevant to treatment, ideally using a geriatric assessment but at least based on a detailed medical history. These deficits can then be presented in a structured, examiner-independent, and forensically validated manner using special assessments. A planned treatment requires not only consideration of survival gains, but also knowledge of specific side effects and, in geriatric patients in particular, their impact on everyday life. These considerations should be compared with the patient's individual risk profile in order to prevent side effects from negating the effect of the treatment, for example by worsening the patient's self-help status. With regard to androgen deprivation in prostate cancer-which often is used uncritically-it is important to consider possible side effects such as osteoporosis, sarcopenia, anemia, and cognitive impairment in terms of a possible fall risk; an increase in cardiovascular mortality and the triggering of a metabolic syndrome on the basis of preexisting cardiac diseases or risk constellations; and to carry out a careful risk-benefit analysis.

[Polypharmacy and medication review in the context of prehabilitation]. / Polypharmazie und Medikamentencheck im Kontext der Prähabilitation.

Against the background of typical geriatric multimorbidity and with the particular vulnerability of geriatric patients, polypharmacy deserves special attention. In accordance with the guidelines, medication should not only be reviewed regularly, but also on an ad hoc basis and with each hospital stay-and also in the context of prehabilitation. Thus, not only substances that interfere with the currently planned intervention, anesthesia, or risk of bleeding should be considered, but any medication that increases common risks for geriatric patients. These include drugs that cause or increase a tendency to fall, induce delirium, or alter the comedication through potential drug-drug interactions. Measures to minimize the risk include the following: exact documentation of medications, structured and complete transfer of information, patient and family training about any side effects that may occur, a recall system for possible laboratory checks, and compliance with the instructions for taking the medication.

[Quality of life for wearers of a suprapubic or transurethral bladder catheter as lifelong permanent care]. / Lebensqualität bei Trägern eines suprapubischen oder transurethralen Harnblasenkatheters als lebenslange Dauerversorgung.

BACKGROUND: The insertion of a Foley catheter (FC) or a suprapubic catheter (SPC) in lifelong intent is an intervention with significant complications, comorbidities and impact on the further life that has not yet been analyzed. METHODOLOGY: The analysis was based on a validated assessment of catheter-related QoL with 25 items in 5 domains and applied to patients with a Foley or suprapubic catheter in lifelong indication and with the catheter in place for at least 3 months. Assessment data were enriched with information on the type and diameter of the catheter as well as demographic data. RESULTS: Questionnaires from 357 patients (260 male, 97 female, 193 with suprapubic catheter, 162 with Foley catheter, 2 no information) were included in the study. Patients with a Foley catheter were significantly older than patients with a suprapubic catheter (78.9 ± 11.1 years vs. 74.4. ± 12.6 years, p < 0.001). The average QoL score was 4.1 points on a scale from 1 (maximum impairment of QoL) to 5 (no impairment of QoL) indicating a moderately negative impact on QoL. Scores below the average were mainly driven and accompanied by a fear of urine leakage, urine odor, painful catheter changes and urinary infections increasing with age. Additionally, patients were worried about negative effects on their daily life activities due to the catheter. These worries seemed to be more pronounced in females with urinary incontinence, patients with a catheter size ≥ 18 Ch. and with an age of < 70 years. The type of catheter showed a greater impact on the QoL in females with suprapubic catheters when compared with males in contrast to patients with transurethral catheters. CONCLUSION: The results of the study provide further information for the medical clarification for patients and caregivers, having to decide between a lifelong catheter drainage or alternatives, such as provision of an aid or surgical recanalization.

[Are there benefits for catheter valves for catheter-associated quality of life? : Results of an investigation in 427 catheter wearers with life-long indication]. / Hat eine Ventilversorgung Vorteile bei der katheterassoziierten Lebensqualität? : Ergebnisse einer Untersuchung an 427 Katheterträgern in lebenslanger Indikation.

BACKGROUND: In urology, a subset of patients with lifelong urine drainage are fitted with a catheter valve. Data on catheter-related quality of life (crqol) in this subset of patients are missing. AIM: Clarification of the whether there are advantages for valve-aided catheters in comparison with continuous urine drainage in catheter wearers with a lifelong indication. METHODS: In all, 357 patients with a catheter with lifelong indication of continuous urine drainage from a previous study were compared with 70 valve-aided patients. The crqol was evaluated by a validated assessment with 25 items and five domains. RESULTS: There were statistically more patients with a suprapubic catheter than with a transurethral indwelling catheter (73.4 vs. 54.4%, p = 0.005), significantly more patients with bladder voiding dysfunction (73.5 vs. 52.6%, p = 0.003) and significantly more patients with small catheter sizes (p = 0.001). Crqol was altogether slightly impaired with a median score of 4.2 (no impairment indicated by 5 points) in valve-aided patients, but crqol was more impaired in valve-aided patients compared to patients with continuous drainage (4.4 points, n. s.). Some items demonstrated more problems dealing with urinary urge in valve-aided patients, but catheter-related pain was more often worse in patients with continuous drainage. CONCLUSION: There is no clear evidence for an advantage of a catheter valve over a continuous urine drainage system. Thus, the decision regarding a catheter-valve system must be made individually according to the indication and the preferences of the patient.

[Concepts in geriatric uro-oncology]. / Uroonkologische Konzepte im Alter.

Uro-oncology is not only concerned with treatment methods themselves but also with therapeutic objectives and decision-making concepts involving algorithms. We discuss whether the latter is applicable to all patients groups or needs to be adapted in order to be suitable for elderly and frail patients with regard to their lifestyle and living situation as well as their altered physiology.

[Prevention of penile cancer. Value of the HPV vaccination and circumcision]. / Primärprävention des Peniskarzinoms. Nutzen der HPV-Impfung und Zirkumzision.

Penile cancer is rare. Penile cancers appear predominantly in non-circumcised men. In addition, the majority of penile cancers are associated with human papillomavirus infection. The present manuscript is concerned with the value of circumcision and HPV vaccination in the prevention of penile cancer.

DNA-ploidy, G2M-fractions and prognosis of stages B and C prostate carcinoma.

Paraffin embedded tissue of 49 stage C and 27 stage B prostate adenocarcinomas was investigated by flow cytometry. All patients were treated by radical prostatectomy with pelvic lymphadenectomy and followed up for 5-10 years. The tumour was separated from the benign tissue to increase the proportion of tumour cells. Ten stage C and seven stage B carcinomas had to be excluded because of poor fixation. Six of the 39 (15%) stage C and 1/20 (5%) stage B carcinomas were aneuploid. Cell cycle analysis was done with correction for sliced nuclei and background subtraction. The threshold between carcinomas with low and with increased ("tetraploid") G2M-fraction was determined by comparing carcinomas with and without tumour progression. Sixty-seven percent of the patients with non-euploid stage C carcinomas and 11% of those with euploid carcinomas suffered from tumour progression (P < 0.01). The respective values for the stage B carcinomas were 67% and 6% (P < 0.01). These results demonstrate the strong prognostic impact of DNA-ploidy and G2M-fractions for each individual patient.

[Immunotherapy of metastatic renal cell cancer]. / Immuntherapie beim metastasierten Nierenzellkarzinom.

In the treatment of advanced renal cell carcinoma, cytokines such as interferons, interleukin-2, tumor necrosis factor and immune therapy with autologous tumor cells and tumor cell vaccines have been tested on a large scale. A definitive cure of a patient with advanced renal cell cancer treated with cytokines or immune therapy has so far not been reported in the literature. The rates of objective remissions (PR and CR) are disappointing and rarely exceed 20% overall. The combination of interferon-alpha and interleukin-2 administered subcutaneously seems to offer the best results with the lowest morbidity. However since standard treatment protocols do not exist, treatment of patients with renal cell carcinoma using these substances should only be performed in prospective trials. Immunotherapy with interferons, interleukin-2, tumor necrosis factor, autologous tumor cells or tumor cell vaccines has to be regarded as experimental.

[Lymph node positive prostate carcinoma. A case for radical prostatectomy]. / Das Lymphknoten-positive Prostatakarzinom. Ein Fall für die radikale Prostatektomie.

Lymph node positive carcinoma of the prostate (stage pN +/D1) is generally considered to be systemic disease that cannot be cured by radical prostatectomy. Treatment options in these minimally metastasized tumors are the wait and watch strategy, hormonal therapy, radiotherapy and radical prostatectomy alone or in combination. At present, there are no prospective randomized trials available regarding the value of these treatment modalities. In retrospective studies, the results of radical prostatectomy seem to be superior to conservative management. In several studies comparing radical prostatectomy vs. pelvic lymphadenectomy alone, a higher tumor burden in the lymphadenectomy alone groups is present. In general, radical prostatectomy reduces local complications of prostate carcinoma and improves quality of life. In conclusion, patients with single or low volume lymph node metastases as well as patients with low tumor grade or favorable Gleason score and diploid tumors seem to benefit from radical prostatectomy. However, the definitive role for radical prostatectomy has to be stated as uncertain.

[What should be done in positive margins after radical prostatectomy?]. / Was ist zu tun bei positivem Absetzungsrand nach radikaler Prostatektomie?

In the last years radical retropubic prostatectomy has become the treatment of choice for locally confined prostate cancer (PCa). However, in the literature local recurrence is described in 4-23% of patients with clinical stage T1-2 prostate cancer and in 43% of patients with clinical stage T3 respectively. The problem is further aggravated that postoperatively raised PSA values are detected in 6-8% of patients with locally confined prostate cancer indicating either local residual tumor or systemic disease. Current datas show that wait-and-watch appears to be the best option for patients with locally confined prostate cancer and positive margins. In case of persistent or raising PSA-values following prostatectomy without detectable local recurrence or metastasis mere local therapy cannot be recommended. Primary radiotherapy should be considered in cases with confirmed clinical local recurrence without distant metastasis. Further prospective and randomized trials have to be initiated to identify the patients with positive margins who will benefit from adjuvant treatment.

[Value of PSA density determination in prostate carcinoma]. / Wertigkeit der PSA-Dichtebestimmung beim Prostatakarzinom.

The PSA density was calculated in 98 patients with carcinoma of the prostate by using the weight and/or volume of the radical prostatectomy specimen. In 22 of 98 patients, PSA serum levels ranged between 4 and 10 ng/ml. Eleven patients showed PSA serum levels below 4 ng/ml and 65 patients above 10 ng/ml. Sixty-one of the 65 patients with PSA serum levels > 10 ng/ml had PSAD values above 0.15, and we therefore suspected the presence of carcinoma of the prostate according to Benson et al. Twelve of the 22 patients with PSA serum levels between 4 and 10 ng/ml had PSAD values below the cut-off value of 0.15. In addition, all 11 patients with PSA values < 4 ng/ml showed PSAD values < 0.15, a range that can be regarded as almost harmless according to Benson et al. In conclusion, it seems apparent that in patients with PSA serum levels < 10 ng/ml, no important additional information is obtained from the PSAD determination. Routine measurement of PSAD for evaluating the risk of carcinoma of the prostate in individual cases can therefore not be recommended.

[Selection criteria for radical prostatectomy with reference to long-term results]. / Selektionskriterien für die radikale Prostatektomie unter Berücksichtigung von Langzeitergebnissen.

Between July 1969 and May 1991 radical prostatectomies were performed in 410 consecutive patients with prostate cancer at the Department of Urology, University of Würzburg. The calculated survival rates for these 410 patients up to 15 years after surgery are very similar to the life expectancy of the normal male age-matched population. In 127 of the 410 cases radical prostatectomy was carried out more than 10 years ago, so that the data relating to these cases have been definitely observed, not merely statistically evaluated. In order to permit a comparison of our results with those reported in the literature, the TNM classification of 1979 was utilized in this study. This means that only tumors penetrating through the capsule of the prostate were classified as stage pT3. Those tumors that are only infiltrating the apex or the prostatic capsule, are classified as stage pT2. For patients with stage pT1pN0M0 and pT2pN0M0-tumors, 10-year survival rates (90.5% and 70% respectively) were recorded which are even slightly better than those of the normal male age-matched population. For patients with tumors extending through the capsule, the 10-year survival rate was found to be 60%. Forty percent ot these patients with stage pT3pN0M0 disease are alive tumor-free after more than 10 years and can thus be regarded as cured. When lymph node metastases were present (stage pT2-3pN1-2M0), some of the patients appeared to benefit from radical prostatectomy, since 4 out of 11 patients with this stage disease survived for more than 10 years.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary renal plasmacytoma. A case report]. / Primäres renales Plasmozytom. Ein Fallbericht.

We describe a patient with a primary renal plasmacytoma. In the literature available, only six clinical cases have been reported. A 64-year-old patient is presented who had the clinical signs of a renal cell carcinoma. Histological examination after nephrectomy, however, revealed a plasmacytoma. Based on this case, we discuss how one should proceed in this disease. Primary renal plasmacytoma can be tentatively diagnosed preoperatively only in the presence of paraproteinemia or Bence-Jones proteinuria, as it cannot be distinguished from other renal tumors by imaging procedures. Postoperatively, further staging procedures must rule out bone involvement (solitary myeloma or multiple myeloma). Nephrectomy is required in patients with plasmacytoma only if renal complications occur.

[Value of transrectal ultrasound in determining the T-stage of prostate cancer]. / Wertigkeit der transrektalen Sonographie bei der Beurteilung des T-Stadiums des Prostatakarzinoms.

Accurate preoperative staging of prostate adenocarcinoma is especially important before radical prostatectomy. The purpose of this prospective study was to investigate the staging accuracy of transrectal ultrasonography in prostatic adenocarcinoma. The results of the preoperative staging evaluation in 126 patients with endorectal ultrasound were compared with the histopathologic findings after radical prostatectomy. Correct staging by transrectal sonography was possible in 82 of 126 patients (65%). For stage pT3 tumors, sensitivity, specificity and positive predictive value were 69%, 51% and 82% respectively.

[Screening in prostate carcinoma]. / Screening beim Prostatakarzinom.

With an increasing incidence, prostate cancer has become the most common cancer in males in the USA. In Germany, 20,000 new cases of prostate cancer were detected in 1995. Only organ confined prostate cancer is curable. Therefore the main intention of screening is an increasing detection rate of clinically significant tumors in time. Cancer specific mortality and morbidity should be decreased by screening. Whether screening can actually achieve this has to be proven in prospective randomized trials, which have only been started recently. Therefore, valid results cannot be expected before the year 2007. Different trials revealed the combination of digital rectal examination and the measurement of prostate specific antigen to be the most useful tools in screening at present. In conclusion, at present, the recommendation is an urological examination once a year in men from 45-50 (depending on risk) to 70-75 years of age--if the patient agrees to the possible diagnostic and therapeutic consequences.

[Paraneoplastic hyperthyroidism in a patient with metastasizing teratocarcinoma and excessively high HCG]. / Paraneoplastische Hyperthyreose bei metastasiertem Teratokarzinom mit exzessiver HCG-Erhöhung.

Clinically manifest hyperthyroidism is a rare paraneoplastic syndrome in patients with excessive HCG production due to testicular cancer. A 40-year-old patient with right testicular cancer (teratoma, embryonal cell carcinoma), diffuse pulmonary metastases and high serum HCG levels presented with symptomatic hyperthyroidism. The patient received immediately thyrostatic therapy and 4 cycles of PEI chemotherapy (Cisplatin, Etoposide, Ifosfamide). Thyroid function had returned to normal by the beginning of the second course of chemotherapy. After right orchiectomy and resection of residual pulmonary masses which revealed vital tumor cells, two additional courses of chemotherapy were performed. The patient is well and without evidence of disease 11 months after therapy. All patients with testicular cancer and excessive HCG production should be evaluated for biochemical and clinical signs of hyperthyroidism and treated accordingly with antithyroidal medication and immediate cytoreductive chemotherapy.

[Syndrome of persisting mullerian duct with first manifestation in an adult]. / Syndrom des persistierenden Müller-Ganges mit Erstmanifestation beim Erwachsenen.

INTRODUCTION: We report on a 22-year-old male patient who presented with an intrapelvic tumor. CASE REPORT: CT and MRI showed a left pelvic abscess, which was drained. After regression of the abscess, we removed the causative tubular structure surgically, revealing a rudimentary genital structure with parts of the Mullerian and Wolffian ducts. CONCLUSIONS: This case report demonstrates an abscess formation as complication of a previously asymptomatic rudimentary genital structure, which was associated with further abnormalities, such as left testicular agenesia, perineoscrotal hypospadias and transverse testicular ectopia.

Value of prostate-specific antigen as a tumor marker.

Prostate-specific antigen (PSA) is the most important tumor marker for prostate cancer. However, the diagnostic limits of PSA have to be taken into consideration because PSA is also secreted by normal prostate tissue and, with benign prostatic hyperplasia, false positives are possible. Although there is a direct correlation between the serum PSA concentration and the clinical stage of the tumor, PSA is not sufficiently reliable to determine the stage of the disease on an individual basis. Low serum PSA concentrations (less than 20 ng/ml) in patients with previously untreated prostate cancer seem to be predictive for a negative bone scan. Serum PSA values also reflect the prognosis of the patient. With respect to monitoring patients after definitive therapy, PSA is a very sensitive tumor marker. However, in a small number of patients PSA-negative tumor recurrences occur.