[Urinary bladder cancer as a late sequela of spinal cord injury : Decision-making aids for assessment of this causal association]. / Harnblasenkarzinom als Spätfolge einer Querschnittlähmung : Entscheidungshilfe für eine Zusammenhangsbegutachtung.

BACKGROUND: There is to date no convincing literature that has assessed the association between traumatic spinal cord injury (SCI) and the later development of urinary bladder cancer. The aim of this work is to present medical experts as well as the national accident insurance and the social courts decision-making aids based on the latest medical scientific knowledge, for assessment of this causal association. MATERIALS AND METHODS: A study conducted between April 1998 and March 2017 in the BG Trauma Hospital Hamburg forms the basis for the decision-making aids. Urinary bladder cancer was diagnosed in 32 out of 6432 treated outpatient and inpatient SCI patients. Furthermore, relevant published literature was taken into consideration for the decision-making aids. RESULTS: It was found that urinary bladder cancer in SCI patients occurs at a considerably younger age as compared to the general population, more frequently shows muscle invasive carcinoma with a higher grade at first diagnosis and a higher proportion of the more aggressive squamous cell carcinoma than that of the general population. Correspondingly, the survival time is extremely unfavorable. For medical experts a matrix was compiled where the various influencing factors, either for or against the recognition of an association between SCI and urinary bladder cancer, were weighted according to their relevance. CONCLUSION: The results showed that urinary bladder cancer in SCI patients differs considerably from that of able-bodied patients. These differences drastically shorten the survival time. A study on patients with spina bifida, i.e., a congenital spinal cord disorder, corroborates these observations. They indicate histopathological differences that have so far been intangible.

[Treatment mapping of lower urinary tract symptoms due to benign prostatic hyperplasia-an analysis of the Governing Body of German Prostate Centers]. / Versorgungsabbild des benignen Prostatasyndroms ­ eine Analyse des Dachverbandes der Prostatazentren Deutschlands (DVPZ) e. V.

BACKGROUND: Due to the high incidence and demographic development, there is an urgent need for healthcare research data on lower urinary tract symptoms due to benign prostatic hyperplasia (LTUS/BPH). Since 2005 the Governing Body of German Prostate Centers (DVPZ) has been collecting data from 22 prostate centers in order to determine the quality and type of cross-sectoral care in particular for LUTS/BPH patients. OBJECTIVES: Presentation of the DVPZ database in general, as well as an investigation of treatment patterns for medical and instrumental therapies. MATERIALS AND METHODS: The analysis is based on UroCloud data sets from 30 November 2017. In the UroCloud data on diagnostics, therapy and course of disease are recorded in a web-based manner. RESULTS: A total of 29,555 therapies were documented for 18,299 patients (1.6/patient), divided into 48.5% instrumental, 29.2% medical treatment, and 18.0% "wait and see" (in 4.3% no assignment was possible). Patients treated with an instrumental therapy were oldest (median: 72 years, interquartile range: 66-77), had the largest prostate volumes (50 ml, 35-75 ml), and were mostly bothered by symptoms (International Prostate Symptom Score = 19/4). The majority of patients under medical treatment received alphablockers (56%); phytotherapeutics were used least frequently (3%). Instrumental therapies are dominated by transurethral resection (TUR) of the prostate (60.0%), open prostatectomy (9.4%) and laser therapy (5.0%), with laser therapy having the shortest hospital stay (5 days) and the lowest transfusion and re-intervention rates (1.0% and 4.6%, respectively). CONCLUSIONS: The DVPZ certificate covers the complete spectrum of cross-sectoral care for LUTS/BPH patients and documents the use of the various therapies as well as their application and effectiveness in the daily routine setting.

[Procedures for determining occupational diseases in cases of urological disorders]. / Das Berufskrankheitenverfahren bei urologischen Erkrankungen.

According to section sign 202 of the German Social Security Code VII, individuals diagnosed with bladder cancer or renal cell cancer who had been occupationally exposed to carcinogens known to induce cancer in these human tissues must be reported to the statutory accident insurance. In this paper, the course of the administrative procedure, particularly considering the reporting procedure and screening for occupational risk factors by a CD-based tool, developed by the authors, is described.

The real-life safety and efficacy of vardenafil: an international post-marketing surveillance study--results from 29 358 German patients.

We assessed the safety, efficacy and patient acceptability of vardenafil (Levitra, Bayer HealthCare, Leverkusen, Germany) under real-life conditions in patients with erectile dysfunction (ED) in a multinational post-marketing surveillance study. An initial and up to two follow-up visits were documented for 29 358 German ED patients receiving vardenafil. Patients were interviewed about overall treatment success, and individual sexual attempts were evaluated in a patient questionnaire. Overall erectile improvement was reported by 93.9% of physicians, and similar improvement rates were reported for both 10 mg and 20 mg vardenafil dosages. Most patients experienced improved erections after the first (73.6%) or second (88.5%) tablet. Sexual attempts were successful with respect to partner penetration in 94.9% of patients and with respect to maintenance of erection during intercourse in 87.7% of patients. Adverse drug reactions were very rare (1.3% of patients). Vardenafil was highly effective, reliable and well tolerated in ED patients treated under real-life conditions.

[Treatment mapping of prostate cancer in DVPZ prostate centers in Germany]. / Versorgungsabbild zum Prostatakarzinom in DVPZ-Prostatazentren in Deutschland.

BACKGROUND: In prostate centers of the Governing Body of German Prostate Centers (DVPZ, Dachverband der Prostatazentren Deutschlands e.V.) treatment data from 3 university clinics, 21 treatment clinics, 3 private clinics and 330 general practitioners incorporated under 22 certificates are collated, in order to document the quality and type of cross-sectoral and interdisciplinary treatment, in particular of prostate cancer (PCA) patients. METHODS: This analysis is based on the DVPZ UroCloud data sets from 20 July 2015. The UroCloud reflects the web-based chronological disease development and quality parameters. For the descriptive analysis of particular key figures, available complete data sets were selected. RESULTS: Of the centers 22 held a valid certificate and fulfilled all required case numbers and structural prerequisites at the primary certification or recertification. In three cases a reauditing led to requirements before certification. Since 2005 a total of 9650 PCA patients have been pseudonymized and followed up (41,247 follow-up forms, 4.3 forms per patient). In 2014 the median number of newly documented PCA patients was 61 per center (minimum 7 and maximum 295). Radical prostatectomy (RP) dominated with 4491 (56 %) cases followed by primary hormonal therapy (1210 cases, 15 %), irradiation (809, 10 %) and non-interventional therapy, such as active surveillance (AS) or watchful waiting (WW) in 760 cases (10 %). A prostate-specific antigen (PSA) reduction was documented in 50 % of the patients with a preoperative PSA value > 20, in 60 % of pT4 tumors and in 50 % of patients with a tumor Gleason score of 9-10. A positive incision margin (R+) was found in in 15 % of pT2 stages, 41 % of pT3 stages and 85 % of pT4 stages. A secondary intervention was documented in 6.5 % of RP. CONCLUSION: The DVPZ certificate reflects the complete spectrum of treatment of PCA patients. The strength of the certificate lies in the documentation of patient development and a simultaneous collation of quality parameters.

[Results of single-stage repair of distal hypospadias using the King modification]. / Ergebnisse der einzeitigen distalen Hypospadiekorrektur in der Modifikation nach King.

From 1975 to 1986 34 patients undergoing repair of distal hypospadias between the age of 2 and 11 were explored. Standard method of the one-stage correction of distal hypospadias without or with moderate chordee was the operative technique according to the modification of King. After rolling the urethral groove into a tube the neourethra is covered with an asymmetrical part of dorsal hood. Thus the operative aims such as nonproblematic micturition, normal cohabitation and ejaculation and a good cosmetic result, avoiding psychological problems, can be obtained. The total complication rate was 23.4%; the correction of urethral fistulas in two layers as ambulatory operations was nonproblematic. By using Silastic foam the incidence of postoperative edema could be reduced significantly.

[Revascularization of the penis in vascular-induced erectile dysfunction: clinical results of the Hauri surgical method]. / Die Revaskularisation des Penis bei der vaskulär bedingten erektilen Dysfunktion: klinische Ergebnisse der Operationsmethode nach Hauri.

Hauri's modification of the procedure for operative penile revascularization has been known since 1983; it is characterized by an anastomosis between the inferior epigastric artery and the dorsal artery of the penis with an arteriovenous shunt with the deep dorsal vein of the penis. Since 1986 this surgical technique has been applied in 18 patients with vascular erectile dysfunction. Their average age was 47 years, and the mean observation period was 8 months. We did not consider the operation indicated unless the presence of pathologic vessels was demonstrated in the distal region of the internal pudendal artery by selective arteriography. After the operation, a 6-month therapy with platelet aggregation inhibitors is necessary. At postoperative follow-up 12 of the 18 patients reported that their sex life was unrestricted and they had spontaneous erections.

[Value of cryotherapy in localized prostatic carcinoma]. / Die Bedeutung der Kryotherapie beim lokalisierten Prostatakarzinom.

Prostate cancer represents the second most frequent malignant male disease in Germany. In the United States, approximately 35,000 men die from prostate cancer annually. The treatment of this disease is of particular interest to both clinical and investigative urologists. Radical prostatectomy and radiotherapy are established standard modalities in the treatment of organ-confined prostate cancer. As in other fields of urology, minimally invasive procedures have gained increased interest in urologic oncology. With cryoablation of the prostate, a minimally invasive therapy for prostate cancer has been available since 1989 and has been used and under investigation since then. Improvements in cryotechnique and progress in transrectal high-resolution ultrasonography enable the surgeon to achieve the curative target of thermoinduced destruction of the whole prostate gland. Control with thermocouples, ultrasound, and double-freeze techniques makes it possible to destroy the whole organ or the region of interest in high-risk patients or in patients who refuse to undergo open surgical procedures.

[Microsurgical testicular denervation as therapy option in chronic testalgia]. / Die mikrochirurgische testikulre Denervierung als Therapieoption der chronischen Testalgie.

Chronic testicular pain represents a challenging urological chronic pain syndrome in terms of adequate diagnosis and therapy. Reported success rates of 55-73% and 10-40% of conservative and surgical interventions are extremely low. We report on microsurgical testicular denervation as therapeutic option in patients with chronic testicular pain (CTP). 12 consecutive patients with CTP were included in our study. After complete diagnostic workup and positive response to testicular nerve blockade, all patients underwent surgery: the cremasteric muscle was dissected by electrocautery, the periadventitial layer of the testicular artery was dissected over a length of 2-3 cm. After a median follow-up of 20.6 months (4-62) 11/12 patients (92%) are pain free. None of the patients suffered from intraa- or postoperative complications. Based on our experience microsurgical testicular denervation should be performed in patients with CTP and no underlying organic disease. However, the high success rate of our surgical procedure can only be maintained if the selection of suitable patients is performed very carefully and a specific organic origin of CTP has been excluded prior to surgery.

[Lumbar radical nephrectomy. A retrospective analysis of 186 cases]. / Lumbale radikale Nephrektomie. Eine retrospektive Analyse von 186 Fällen.

186 cases of nephrectomy for renal cell cancer are studied retrospectively. The overall 5-year survival rate was 77.2%. According to the 4th edition of the "TNM" classification system of UICC the survival rates of patients with T2-(n = 97), T3a (n = 58) and T3b-tumors (n = 25) were 80.9%, 79.3% and 65.6%, respectively. No patient with a stage T4 tumor (n = 6) survived longer than 20 months. The 5-year survival rate of patients with N1-lymph node metastases was 83.3% (n = 8); without lymph node metastases 78.3% (n = 152), respectively. There was no survival longer than 20 months in case of N2-lymph node metastases (n = 13). According to the grading survival rates of 95.4% (G1, n = 46), 71.2% (G2, n = 130) and 71.4% (G3, n = 8) resulted.

[Testicular epidermoid cyst: orchiectomy or enucleation resection?]. / Testikuläre Epidermiszyste: Orchiektomie oder Enukleationsresektion?

Our experience with 18 patients with simple epidermoid cysts of the testis is reported. In each patient the tumour was enucleated completely and two biopsies of the adjacent parenchyma were obtained for exclusion of associated germ cell cancer, scars or carcinoma in situ. There was no evidence of malignancy in any of the biopsy specimens. Preoperative evaluation included physical examination, testicular sonography, and determination of AFP and hCG serum levels. Although epidermoid cyst can be strongly suspected on sonography the ultrasound appearance is not specific, and inguinal testicular exploration was required in these patients. In 1 patient multiple epidermoid cysts of the right testis were associated with an adult teratoma containing embryonal carcinoma and choriocarcinoma of the left testis; no similar case has been described in the literature. On the basis of our results and experience we consider tumour enucleation and biopsy of the adjacent parenchyma to be adequate treatment for benign epidermoid cyst. The world literature concerning organ-sparing surgery in testicular epidermoid cyst is reviewed.

[Interstitial brachytherapy--a minimal invasive urological option for treatment of prostate cancer of increasing importance]. / Interstitielle Brachytherapie--eine minimal invasive urologische Therapieoption des Prostatakarzinoms mit zunehmender Bedeutung.

As an alternative to a radical prostatectomy with complications reducing the quality of life because of incontinence of urine and erectile dysfunction, the insertion of radioactive sources into the prostate was established in the USA and evaluated by accompanying studies at the beginning of the eighties. The patient has the advantage of minimal-invasive character, the possibility of outpatient treatment and the lower operative morbidity as well as reduced complications. In the locally limited "low-risk" stage (pT1a - pT2c), the American Society for Urology judges it equieffective as a curative treatment as regards the survival period. Although there are long-term studies with a follow-up of 13 years, in Germany we are not able to give our opinion finally, but it can be assumed to be as equally good. Considering the demographic development, one has to expect an increase in this cancer, which today already has the highest cancer rate in men in Germany. The improved diagnosis will lead to an increase in treatments and younger men will be examined. As a result there will be more curable cases and an improvement or even prolongation of the survival period. The trend seen in the USA indicates a rise in this treatment in Germany as well. After a terminological definition of the expression and a presentation of the brachytherapy-technique, the range of actual therapeutical options of prostate cancer and the variations of brachytherapy are shown and compared as far as their efficiency is concerned. Uncertainties in the evaluation of medical necessity are discussed but also contradictions and diversities in the opinions on the mode of accounting.

[New treatment strategies for male lower urinary tract symptoms]. / Neue Behandlungskonzepte von Symptomen des unteren Harntraktes beim Mann.

For patients with lower urinary tract symptoms (LUTS), α1-adrenoreceptor inhibitors and 5-alpha reductase inhibitors as well as their combination are considered the gold standard. In addition, anticholinergic agents are being introduced as monotherapy or in combination with α1-adrenocepetor inhibitors for patients with predominant storage disorders. Phosphodiesterase 5 (PDE5) inhibitors are often the best option for patients with LUTS who also suffer from erectile dysfunction. Recently, novel treatment options have been presented and intraprostatic injection of various agents, such as botulinum toxin A, NX-1207 and PRX302 has shown promising initial results. In addition, innovative minimally invasive treatment options, such as UroLift® appear to be efficacious and safe in this patient cohort. Particular emphasis should be laid on patients with LUTS and concomitant sexual disorders.

[Hyperbaric oxygen in the treatment of hemorrhagic radiogenic cystitis after prostate cancer]. / Hyperbare Sauerstofftherapie bei hämorrhagischer Strahlenzystitis nach Prostatakarzinom.

BACKGROUND: Postradiation hemorrhagic cystitis is a well known long-term complication of radiation therapy occurring in 3-6 % of patients. Hyperbaric oxygen (HBO) has been demonstrated to be an effective treatment for radiation-induced hemorrhagic cystitis not responding to conventional management. This article reviews experiences with HBO for radiogenic cystitis after prostate cancer. METHODS: All patients treated for hemorrhagic cystitis with HBO between 2006 and 2012 were retrospectively reviewed. The HBO procedure was performed for 130 min/day at 1.4 atmospheres overpressure. Patient demographics, type of radiotherapy, onset and severity of hematuria and time between first hemorrhagic episode and beginning of HBO were evaluated. The effect of HBO was defined as complete or partial (lower RTOG/EORTC grade) resolution of hematuria. RESULTS: A total of 10 patients with radiogenic cystitis and a median age of 76 years were treated with a median of 30 HBO treatment sessions. Patients received primary, adjuvant, salvage and high dose rate (HDR) radiotherapy (60-78 Gy). First episodes of hematuria occurred after a median of 41 months following completion of radiotherapy and HBO was performed 11 months after the first episode of hematuria. After a median 35-month follow-up 80% experienced complete resolution, one patient suffered a one-off new hematuria and in one patient a salvage cystectomy was necessary. No adverse effects were documented. CONCLUSIONS: The experiences indicate that HBO is a safe and effective therapy option in treatment-resistant radiogenic cystitis but prospective clinical trials are needed for a better evaluation.

[Certified prostate centers of the DVPZ : Current status]. / Zertifizierte Prostatazentren im DVPZ : Aktueller Stand.

Five years after introduction of the standards for certification of prostate centers of the DVPZ (Dachverband der Prostatazentren Deutschlands e.V., Umbrella Organization of Prostate Centers in Germany), 40 facilities are seeking to obtain certification and 18 have already achieved certification. One center (Leverkusen) has meanwhile been recertified. Accomplishing certification appears to be protracted in parts, mainly due to the required training and involvement of outpatient services. Most of the difficulties encountered in implementing the contents of the certificate were noted in rendering documentation when dealing with health care data from the outpatient sector. The strengths of the DVPZ certificate include the consistent involvement of the outpatient services, continuing education of the cooperating partners, and the provision of the necessary components for establishing a center. There are considerable potentials for improvement regarding the expected and actual implementation of the standards. Efforts to increase quality are not as yet reimbursed by the cost bearers and a joint course of action on the part of the DVPL and the DKG (Deutsche Krebsgesellschaft, German Cancer Society) seems to be needed.

Is there evidence for a multidisciplinary follow-up after urological cancer? An evaluation of subsequent cancers.

INTRODUCTION: Follow-up after cancer treatment has been focussing on the detection of local recurrence or metastatic disease of the primary cancer. Subsequent independent malignancies arising during follow-up have not been considered as relevant. Our study evaluated the risk of independent cancers following the diagnosis of primary urological cancer. MATERIALS AND METHODS: From 1990 to 1998 data from 4,119 patients with a minimum follow-up of 5 years were collected. A total of 1,835 patients had primary prostate cancer, 1,269 and 1,015 patients had primary bladder and renal cell cancer, respectively. The most common subsequent malignancies in males were prostate cancer followed by lung and colon cancer. Breast and colon cancer were the most frequently detected subsequent cancers in females. The age correlated comparison of diagnosed and expected cancer in men with primary prostate cancer revealed an increase in relative risk for bladder, kidney and rectal cancer of 3.75, 2.03 and 1.32-fold, respectively. In men with primary bladder cancer the relation for prostate, kidney and lung cancer was 4.05, 2.51 and 2.13-fold, respectively; for females the relation for kidney cancer was 4.55-fold. In men with primary kidney cancer subsequent rectal, prostate and bladder cancer showed a 4.38, 2.91 and 2.48-fold increase, respectively. CONCLUSION: These data suggest an increase in relative risk for subsequent urologic and non-urologic cancer during follow-up. Clinicians involved in oncological follow-up need to be aware of this finding. To which degree a follow-up scheme, not solely focussing on the primary urological malignancy could improve survival needs to be evaluated in further studies.

Diagnosis and follow-up of testicular carcinoma in situ by DNA image cytometry.

Carcinoma in situ (CIS) of the testis has been described as precursor of all types of germ cell cancer except spermatocytic seminoma. At present the diagnosis of CIS is based on light microscopic examination of a testis biopsy specimen. A series of 50 infertile patients underwent both surgical testis biopsy and aspiration biopsy as part of a study protocol in order to assess spermatogenesis. In 1 patient embryonal carcinoma and contralateral CIS was diagnosed, in 1 patient bilateral CIS was discovered. Diagnosis of CIS was made by DNA image cytometry of the testis aspiration biopsy: a typical aneuploid cell population was shown consistent with malignancy. Follow-up was performed by repeated aspiration testis biopsies: DNA histograms showed complete absence of haploid cells consistent with Sertoli-cell-only syndrome in the patient with unilateral germ cell cancer and contralateral CIS treated with localized radiation. In the other patient no treatment was performed and DNA histograms continuously showed an aneuploid cell population consistent with persistent CIS. No invasive cancer developed within 4 years after diagnosis. Our results underline the potential use of DNA cytometry in the diagnosis and follow-up, of CIS of the testis offering the advantage of an objective and rapid technique.

[The determination of patient satisfaction as a part of quality management in the hospital]. / Die Bestimmung der Patientenzufriedenheit als Teil des Qualitätsmanagements im Krankenhaus.

BASIC PROBLEM AND OBJECTIVE OF STUDY: Patient-satisfaction is an important part of the quality of results of medical treatment in hospital. Such satisfaction can be measured with a standardised multi-dimensional questionnaire which takes into account all relevant parts of a hospital. An enquiry was undertaken on patients in a university department of urology to find out whether a scientifically based measurement of patient-satisfaction is possible and whether organisational improvement can result from it. PATIENTS AND METHODS: Dimensions of patients-satisfaction included "care by doctors", "care by nursing staff", "food and accommodation", and "administration and daily activity". A questionnaire with a scale for answers (total of 65 items with closed answers) was developed for each of the dimensions. A one-month pretest served to ascertain acceptance and understanding of the questionnaire. In the three-month main test period questionnaires were given to all in-patients over 16 years old on admission. Participation was voluntary and anonymous. RESULTS: 232 patients took part (172 men, 60 women; median age 57 years), a response rate of 61%. The scales were shown to have a high internal consistency. The answers provided, for example, the means for simple and directly applicable improvement in patient information and the organisation of daily routine. Making the results known had a positive effect on the motivation of the staff. CONCLUSION: The work and cost involved in such a study are reasonable. This is the more so since in future investigation on patient-satisfaction will be undertaken every year or two as part of the demanded quality management in hospitals. However, scientific principles in the methodology must be taken into account when evaluating the results.

Cryoablation of localized prostate cancer: neoadjuvant downsizing of prostate cancer with LH-RH analogue depot before cryosurgery.

Radical prostatovesiculectomy, radiation therapy, and complete androgen deprivation are acknowledged therapeutic concepts in the treatment of organ-confined prostate cancer. With cryoablation of the prostate, minimal invasive therapy has become available since 1991. Improvements in cryotechnique and progress in transrectal high-resolution ultrasound permit thermo-induced damage to the whole gland to be curative. Downstaging of prostate cancer by hormone ablative therapy remains a controversial issue at this time, but the use of androgen ablation decreases the size of the prostate gland which facilitates cryosurgery and improves the results. The freezing equipment has a limited capacity, and in certain instances large gland volumes prevent adequate freezing of the prostate. Since percutaneous prostate cryosurgery leaves dead tissue in situ to be resorbed over time, downsizing reduces the amount of necrotic tissue to be resorbed, reducing the potential for complications, particularly abscesses. The use of androgen ablation also increases the deposition of fat in the area of the Denonvillier's fascia, making freezing of the rectum less likely during the procedure. In our study androgen ablative therapy was completed before performing cryosurgery in 26 of 43 patients (58%). The 17 patients not given androgen ablation therapy had gland volumes < 40 ml, tumor volumes < 3 ml, and no evidence of extracapsular tumor. The neoadjuvant therapy consisted of a 3- to 10-month course of leuprolide acetate combined with an antiandrogen.