[Traumatic injuries of the kidney and the urinary tract in blunt abdominal trauma]. / Traumatische Verletzungen der Nieren und der ableitenden Harnwege bei stumpfen Bauchtraumata.

BACKGROUND: In the context of blunt abdominal trauma, injuries to the urinary tracts often occur, especially in polytrauma patients. Urotrauma is rarely immediately life-threatening but can lead to serious complications and chronic functional limitations during treatment. Therefore early urological involvement is crucial for adequate interdisciplinary treatment. METHODS: The most important facts for the clinical routine on the consultant urological management of urogenital injuries in blunt abdominal trauma are discussed according to the European "EAU guidelines on Urological Trauma" and the German "S3 guidelines on Polytrauma/Treatment of Severely Injured Patients" as well as the relevant literature. RESULTS: Urinary tract injuries can occur even with an initially inconspicuous status and always require explicit exclusion diagnostics by means of contrast medium tomography of the entire urinary tract and, if necessary, by means of urographic and endoscopic examinations. The most common urological intervention is catheterization of the urinary tract which is often required. Less common is urological surgery, which should be coordinated interdisciplinarily with visceral and trauma surgery. More than 90% of vitally threatening kidney injuries (usually up to the American Association for the Surgery of Trauma (AAST) grades 4-5) are now treated by interventional radiology. CONCLUSION: Due to possible complex injury patterns in blunt abdominal trauma, these patients should ideally be directed to (certified) trauma centers with subspecialized or maximum care from the departments of visceral and vascular surgery, trauma surgery, interventional radiology and urology.

Infection rate and complications after 621 transperineal MRI-TRUS fusion biopsies in local anesthesia without standard antibiotic prophylaxis.

PURPOSE: The aim of this study was to assess the post biopsy infection rate, feasibility and prostate cancer (PCa) detection rate (CDR) by performing transperineal MRI-TRUS fusion biopsy of the prostate (TPBx) under local anesthesia (LA) without antibiotic prophylaxis (AP). METHODS: We prospectively screened 766 men with suspicious lesions on mpMRI, an elevated PSA level or a suspect digital examination undergoing MRI-TRUS-TPBx in LA, from May 2019 to July 2020. Patients with the need for antibiotic prophylaxis or without a PI-RADS target lesion were excluded from final analyses. We reported CDR, perioperative pain (0-10) and postoperative complications. PCa with an ISUP grade ≥ 2 was classified as clinically significant PCa (csPCa). RESULTS: We included 621 patients with a median age of 68 years (IQR 62-74), a PSA of 6.43 ng/mL (IQR 4.72-9.91) and a prostate volume of 45 cc (IQR 32-64). In median, 4 targeted (TB) (IQR 3-4) and 6 (IQR 5-7) systematic biopsies (SB) detected in combination overall 416 (67%) PCa and 324 (52%) csPCa. Overall CDR of TB for PI-RADS 3, 4 and 5 was 26%, 65% and 84%, respectively. Patients reported a median perioperative pain level of 2 (IQR 1-3). Four patients (0.6%) developed a post biopsy infection, one experienced urosepsis. CONCLUSION: Our results demonstrate that transperineal MRI-TRUS fusion-guided prostate biopsy under LA without AP is feasible, safe and well tolerated.

[MRI/TRUS fusion-guided prostate biopsy : Value in the context of focal therapy]. / MRT/TRUS-fusionierte Biopsiesysteme : Stellenwert bei der fokalen Therapie des Prostatakarzinoms.

BACKGROUND: Several systems for MRI/TRUS fusion-guided biopsy of the prostate are commercially available. Many studies have shown superiority of fusion systems for tumor detection and diagnostic quality compared to random biopsy. The benefit of fusion systems in focal therapy of prostate cancer (PC) is less clear. OBJECTIVES: Critical considerations of fusion systems for planning and monitoring of focal therapy of PC were investigated. MATERIALS AND METHODS: A systematic literature review of available fusion systems for the period 2013-5/2016 was performed. A checklist of technical details, suitability for special anatomic situations and suitability for focal therapy was established by the German working group for focal therapy (Arbeitskreis fokale und Mikrotherapie). RESULTS: Eight fusion systems were considered (Artemis™, BioJet, BiopSee®, iSR´obot™ Mona Lisa, Hitachi HI-RVS, UroNav and Urostation®). Differences were found for biopsy mode (transrectal, perineal, both), fusion mode (elastic or rigid), navigation (image-based, electromagnetic sensor-based or mechanical sensor-based) and space requirements. DISCUSSION: Several consensus groups recommend fusion systems for focal therapy. Useful features are "needle tracking" and compatibility between fusion system and treatment device (available for Artemis™, BiopSee® and Urostation® with Focal One®; BiopSee®, Hitachi HI-RVS with NanoKnife®; BioJet, BiopSee® with cryoablation, brachytherapy). CONCLUSIONS: There are a few studies for treatment planning. However, studies on treatment monitoring after focal therapy are missing.

[Implications of PI-RADS Version 1 and Updated Version 2 on the Scoring of Prostatic Lesions in Multiparametric MRI]. / Prostataläsionen im multiparametrischen MRT: Vergleich der Einflüsse von PI-RADS Version 1 und 2 auf das Scoring.

BACKGROUND: A revised version of the PI-RADS scoring system has been introduced and score-related variability between version 1 and 2 may be suspected. This study aimed to assess the PI-RADS scores derived from version 1 (v1) and the updated version 2 (v2). MATERIAL AND METHODS: 61 patients with biopsy-proven prostate cancer (PCa) and 90 lesions detected on pre-biopsy 3-Tesla multiparametric MRI were included in this retrospective analysis. 2 experienced radiologists scored all lesions in consensus. Lesion scores differing between PI-RADS v1 and v2 were further analyzed. Histology data from radical prostatectomy (RP) were included when available. RESULTS: The PI-RADS v1 and v2 score differed in 52% of patients (32/61) and in 39% of lesions (35/90). On a lesion basis, the reason for the differences were related to sum score in v1 vs. categorical system in v2 in 51% (18/35) of lesions, cutoff between PI-RADS 4 and 5 based on lesion size in v2 as opposed to the sum score in v1 in 31% (11/35) and were inconclusive in 17% (6/35). The RP subgroup indicates enhanced detection of PCas with GS 3+3 and GS 3+4 in v2. CONCLUSION: PI-RADS scores of prostatic lesions frequently differed between v1 and v2, the major reasons for these differences being score-related. In men undergoing RP, PI-RADS v2 improved detection of low risk PCa, but did not increase accuracy for discrimination of GS 3+4 vs. GS≥4+3 compared to v1. Urologists should be aware of the system-related differences when interpreting PI-RADS scores.

[Malignant Sertoli cell tumors of the testes]. / Maligner Sertoli-Zell-Tumor des Hodens.

Sertoli cell tumors are a rare malignancy which account for approximately 1.5 % of all testicular tumors. Although malignant Sertoli cell tumors are uncommon, they are associated with a poor prognosis. So far 36 cases of malignant courses of disease have been described. We present a patient with a lymphogenic metastasized Sertoli cell tumor, who 24 months after orchiectomy and extended retroperitoneal lymphadenectomy is relapse-free.

[Real-time MRI/US fusion-guided biopsy in biopsy-naïve and pre-biopsied patients with suspicion for prostate cancer]. / Die Echtzeit-MRT/US-Fusionsbiopsie in Patienten mit und ohne Vorbiopsie mit Verdacht auf ein Prostatakarzinom.

BACKGROUND: Magnetic resonance imaging (MRI)/ultrasound (US) fusion-guided biopsy detects more prostate cancer (PCa) than transrectal US (TRUS)-guided biopsy in patients with an indication for prostate re-biopsy. The aim of this study was a) to compare the detection rates of MRI/US fusion-guided biopsy with conventional TRUS in a double centre cohort and b) to investigate the influence of the number of pre-biopsies on the PCa detection rate. MATERIAL AND METHODS: In the period from January 2012 to July 2014, 310 consecutive patients gave written informed consent and underwent 3 Tesla MRI scans of the prostate. All patients had at least one PCa suspicious lesion in the MRI and were biopsied by MRI/US fusion followed by a conventional 10-core biopsy of the prostate. Detection rates based on technique, Gleason score and number of pre-biopsies were calculated. RESULTS: The overall detection rate of the study was 51% (158 patients). Among these 158 patients a histopathological Gleason score of 6 was detected in 60 patients (38%), a Gleason score of 7 in 54 patients (34%) and a Gleason score≥8 in 44 patients (28%). MRI/US fusion-guided biopsy detected 110 (69.7%) of the overall detected 158 PCa. TRUS-guided biopsy detected a higher rate of Gleason score 6 (54%) and a lower rate of Gleason score≥8 (15%) lesions in comparison to 38% Gleason 6 and 28% Gleason≥8 in the MRI/US fusion-guided biopsy, respectively. Furthermore, a lower Gleason score was observed in patients with more than one pre-biopsy. The detection rate in biopsy-naïve patients undergoing MRI/US fusion was 75% (40 patients) among 75% detected Gleason score≥7. CONCLUSION: MRI/US fusion-guided biopsy detected more PCa and also more clinically significant cancer than conventional TRUS. In our cohort patients with more than one pre-biopsy showed lower Gleason scores. The included patients with an initial MRI/US fusion-guided biopsy should be further investigated.

[Real-time MRI/US fusion-guided biopsy improves detection rates of prostate cancer in pre-biopsied patients]. / Die Echtzeit-MRT/US-Fusionsbiopsie verbessert die Detektionsrate des Prostatakarzinoms nach mehrfach negativen Vorbiopsien.

BACKGROUND: According to the guidelines of the European Association of Urology (EAU) on prostate cancer (PCa) in 2013, patients with increasing prostate-specific antigen (PSA) levels, suspicious digital rectal examination (DRE) or high-grade prostatic intraepithelial neoplasia after negative prostate biopsy (PB) should undergo a repeat biopsy. Low cancer detection rates in the repeat biopsy illuminate the dilemma of the international gold standard of transrectal ultrasound (TRUS) guided PB in the detection of PCa. Our study evaluated the combination of TRUS and prostate magnetic resonance imaging (MRI) and its reported high sensitivities and high specificities by using real-time MRI/US fusion-guided biopsy. The detection of clinically significant PCa was investigated. MATERIAL AND METHODS: 128 consecutive patients in the period of January 2012 to August 2013 were included. All patients had at least one TRUS-guided biopsy with negative findings and the clinical indication for a systematic re-biopsy. Prior to the MRI/US fusion all patients underwent a 3 Tesla prostate MRI without endorectal coil. The MRI data were uploaded to a modern US system. The B-mode, power-mode, elastography and CEUS imaging were used to classify the suspicious lesions from the MRI on a scale of 0-3 and a US sum score was calculated. The lesion was consecutively biopsied by real-time MRI/US fusion followed by a systematic 10 core biopsy. RESULTS: Among 128 patients 51 PCa could be detected (39.8%). From these 51 PCa cases, clinically significant PCa was detected by MRI/US fusion-guided biopsy as follows: Gleason score >7 in 9 of 10 patients; Gleason score=7 in 14 of 20 patients and Gleason score <7 in 13 of 21 patients. A positive correlation was shown between the US sum score and the associated PI-RADS score in 65 patients in whom lesions were classified by PI-RADS. A positive correlation was further shown between the US sum score and the Gleason score of all suspicious and biopsied lesions. MRI/US fusion and TRUS-guided biopsy combined, detected 30 of 51 PCa; 6 of 51 PCa were detected by MRI/US fusion alone and 15 of 51 PCa by conventional TRUS-guided biopsy alone. CONCLUSION: Real-time MR/US fusion increases detection rates of PCa in patients undergoing repeat biopsy. Especially, clinically significant PCa with a Gleason score ≥ 7 were almost exclusively detected by MR/US fusion-guided biopsy.

[High-intensity focussed ultrasound in low-risk prostate cancer - oncological outcome and postinterventional quality of life of an inexperienced therapy centre in comparison with an experienced therapy centre]. / Hochintensiver fokussierter Ultraschall bei Low-Risk Prostatakarzinom - Onkologisches Outcome und postinterventionelle Lebensqualität im direkten Vergleich eines erfahrenen und unerfahrenen Therapiezentrums.

BACKGROUND: In patients with low-risk prostate cancer (PCa) the standard therapies carry a risk of overtreatment with potentially preventable side effects whereas restrained therapeutic strategies pose a risk of underestimation of the individual cancer risk. Alternative treatment options include thermal ablation strategies such as high-intensity focused ultrasound (HIFU). PATIENTS AND METHODS: 96 patients with low-risk PCa (D'Amico) were treated at 2 HIFU centres with different expertise (n=48, experienced centre Lyon/France; n=48 inexperienced centre Charité Berlin/Germany). Matched pairs were formed and analysed with regard to biochemical disease-free survival (BDFS) as well as postoperative functional parameters (micturition, erectile function). The matched pairs were discriminated as to whether they had received HIFU treatment alone or a combination of HIFU with transurethral resection of the prostate (TURP). Patients of the Lyon group were retrospectively matched through the @-registry database whereas patients of the Berlin group were prospectively evaluated. In the latter patients quality of life assessment was additionally inquired. RESULTS: Postoperative PSA-Nadir was lower in the Berlin group for patients with HIFU only (0.007 vs. Lyon 0.34 ng/ml; p=0.037) and HIFU+TURP (0.25 vs. Lyon 0.42 ng/ml; p=0.003). BDFS was comparable in both groups for HIFU only (Berlin 4.77, Lyon 5.23 years; p=0.741) but patients with combined HIFU+TURP in the Berlin group showed an unfavourable BDFS as compared to the Lyon group (Berlin 3.02, Lyon 4.59 years; p=0.05). In an analysis of Berlin subgroups especially patients who had received HIFU and TURP (n=4) within the same narcosis had an unfavourable BDFS (p=0.009). Median follow-up was 3.36 years for HIFU only and 2.26 years for HIFU+TURP. Neither HIFU only (p=0.117) nor HIFU+TURP (p=0.131) showed an impact on postoperative micturition. Erectile function was negatively influenced (HIFU: p=0.04; HIFU+TURP: p=0.036). There was no measurable change in quality of life after the treatment. CONCLUSION: The 4-year BDFS after HIFU and HIFU+TURP is comparable to that of the standard therapies. The erectile function is sustainably negatively influenced whereas postoperative micturition and quality of life were not affected by HIFU or HIFU+TURP. These results are strongly limited by the low patient count and the short follow-up period and require validation in prospective multicentre studies with higher number of cases.

[HIFU in salvage treatment of patients with prostate cancer after primary external radiation therapy--status 2012]. / HIFU in der Salvage Behandlung von Patienten mit Prostatakarzinom-Rezidiv nach primärer externer Bestrahlungstherapie - Status 2012.

BACKGROUND: Patients with (local) recurrence of prostate cancer after radiation therapy face the question of the appropriate diagnostic and possible therapeutic options. Many patients in this setting receive palliative androgen deprivation therapy alone, with arguable impact on overall cancer survival. In the case of an isolated local recurrence, salvage prostatectomy represents a potentially curative therapeutic option, albeit with a high complication rate. Alternatively, these patients can be offered a local treatment with salvage HIFU therapy. MATERIAL AND METHODS: Salvage HIFU therapy is based on the thermal ablation of tissue through high-intensity focused ultrasound. In addition, the formation of microbubbles (cavitation) and their implosion lead to an enhancement of tissue ablation. RESULTS: The results of 6 monocentric studies (2004-2011) with an overall number of 408 patients (22-167 patients) are presented and critically reviewed. The median follow-up was 18.71 months (7.4-39). The 3-year progression free survival (PFS) varied from 25% (D'Amico high risk) to 53% (D'Amico low-risk), the 5-year overall survival was 90%. The rate of urinary incontinence varied between 7 and 60% in all grades (grade III urinary incontinence 0-9.5%). In 22 cases surgical incontinence treatment was performed. 53 patients developed a urethral stricture or stenosis leading to surgical treatment. Urethral-rectal fistulae were seen in 0-7%. CONCLUSIONS: The current data on salvage HIFU can be evaluated as insufficient. The main criticisms can be seen in the lack of randomization, the monocentric and retrospective analyses of the data, the heterogeneous stratification of risk groups as well as inadequate definition of postinterventional treatment failure. The studies indicate that salvage HIFU therapy leads to a mid-term overall survival with complication rates that are comparable to those of other local salvage therapies. Randomized multicentric studies are needed to further validate the results of salvage HIFU therapy.

[Introduction of interdisciplinary prostate cancer centers based on the recommendations of the German Cancer Society. A cost-benefit analysis 3 years after accreditation]. / Etablierung von interdisziplinären Prostatakrebszentren nach den Empfehlungen der DKG. Eine Kosten-Nutzen-Analyse 3 Jahre nach Zertifizierung.

The introduction of prostate cancer treatment centers according to the criteria of the German Cancer Society ("Deutsche Krebsgesellschaft", DKG) aims at improving the quality of care for patients with prostate cancer. Systematic analyses of the effects and costs are lacking as yet. Three years after certification of the Interdisciplinary Prostate Cancer Center at the Charité Hospital Berlin we observed a decrease in the rate of positive surgical margins (tumor stage pT2), but other parameters of treatment quality including patient satisfaction remained unchanged. A survey among urologists of the region showed a high acceptance of prostate cancer centers in general. The majority of participating urologists appreciated the work of the Charité center, in particular the treatment recommendations given by the center were mostly followed and the majority of urologists regularly use educational activities of the center. However, only 30% of the participating urologists confirmed short-term improvements in the quality of patient care. Yearly additional costs for the Charité prostate cancer center are estimated at 205,000 euro (precertification phase and certification) and 138,000 euro (monitoring phase), despite the initial drop in mean treatment costs per case (radical prostatectomy). The introduction of prostate cancer treatment centers certified by the DKG is cost intensive, increases in treatment efficiency notwithstanding. Short-term improvements in quality of care cannot be unequivocally demonstrated. Prostate cancer centers serve an important role in counseling and medical education and may thus help disseminate evidence-based treatment strategies.

Once-daily vs. continuous aminoglycoside dosing: efficacy and toxicity in animal and clinical studies of gentamicin, netilmicin, and tobramycin.

The dosing frequency of aminoglycoside antibiotics may alter efficacy and toxicity independent of total daily dose. Once-daily tobramycin dosing was compared with continuous infusion in three models of efficacy. Acute pneumonia due to Pseudomonas aeruginosa in guinea pigs responded better to once-daily dosing, and chronic pneumonia in rats and endocarditis in rabbits responded equally to both regimens. Dogs given gentamicin, tobramycin, or netilmicin once daily, with maximum serum concentrations of greater than 100 mg/liter, had less nephrotoxicity than dogs given continuous infusions. Tobramycin was given once daily or continuously to 52 patients with cystic fibrosis who in 10 days had no change in creatinine clearance or hearing despite maximum serum tobramycin concentrations of 40 mg/liter. Intermittent dosing of aminoglycosides, causing infrequent large maximum serum concentrations, may be less toxic and equally efficacious as frequent dosing.

Oral levonantradol in the control of cancer chemotherapy-induced emesis.

A dose-ranging study with oral levonantradol was performed in 20 cancer patients. The optimum oral dose which attenuated vomiting accompanying chemotherapy was 1 mg 4-hourly. Side-effects comprised dizziness, confusion, euphoria, drowsiness, and difficulty in concentrating. There was no cardiovascular toxicity. Overall toxicity appeared to be dose-related and was mild and acceptable.