Commentary on "Detection and oncological effect of circulating tumor cells in patients with variant urothelial carcinoma histology treated with radical cystectomy."

OBJECTIVES: To investigate for the presence of circulating tumor cells (CTC) in patients with variant urothelial carcinoma of the bladder (UCB) histology treated with radical cystectomy (RC), and to determine their impact on oncological outcomes. PATIENTS AND METHODS: We, prospectively, collected data of 188 patients with UCB treated with RC without neoadjuvant chemotherapy. Pathological specimens were meticulously reviewed for pure and variant UCB histology. Preoperatively collected blood samples (7.5ml) were analyzed for CTC using the CellSearch system (Janssen, Raritan, NJ). RESULTS: Variant UCB histology was found in 47 patients (25.0%), most frequently of squamous cell differentiation (16.5%). CTC were present in 30 patients (21.3%) and 12 patients (25.5%) with pure and variant UCB histology, respectively. At a median follow-up of 25 months, the presence of CTC and nonsquamous cell differentiation were associated with reduced recurrence-free survival (RFS) and cancer-specific survival (pairwise P ≤ 0.016). Patients without CTC had better RFS, independent of UCB histology, than patients with CTC with any UCB histology (pairwise P<0.05). In multivariable analyses, the presence of CTC, but not variant UCB histology, was an independent predictor for disease recurrence (hazard ratio = 3.45, P<0.001) and cancer-specific mortality (hazard ratio = 2.62, P = 0.002). CONCLUSION: CTC are detectable in about a quarter of patients with pure or variant UCB histology before RC, and represent an independent predictor for outcomes, when adjusting for histological subtype. In addition, our prospective data confirm the unfavorable influence of nonsquamous cell-differentiated UCB on outcomes.

[Sphincter and corpus cavernosum prostheses as components of endoprosthetics in urology]. / Sphinkter- und Schwellkörperprothesen als Teile der Endoprothetik in der Urologie.

Artificial urinary sphincters and penile corpus cavernosum prostheses are effective for patients who are not adequately treated by conservative treatment or pharmacotherapy. Both of these devices show good results concerning functional outcome if used within the correct patient selection. Penile prostheses are meant to be the last line of treatment for severe erectile dysfunction after failure of conventional treatment. Artificial urinary sphincters are the treatment of choice for severe urinary stress incontinence. Although the surgical procedure is an easy one, only highly experienced centers should perform the implantation due to minimization of infections and loss of function. Because of the hydraulic working principle of both devices, check-ups on a regular basis are strongly recommended. In the case of a loss of function or infections, a rapid and targeted treatment is the key to make new implantations possible in the future.

[Redo urethroplasty with buccal mucosa]. / Redo-Harnröhrenplastik mit Mundschleimhaut.

Urethral strictures can occur on the basis of trauma, infections, iatrogenic-induced or idiopathic and have a great influence on the patient's quality of life. The current prevalence rate of male urethral strictures is 0.6% in industrialized western countries. The favored form of treatment has experienced a transition from less invasive interventions, such as urethrotomy or urethral dilatation, to more complex open surgical reconstruction. Excision and primary end-to-end anastomosis and buccal mucosa graft urethroplasty are the most frequently applied interventions with success rates of more than 80%. Risk factors for stricture recurrence after urethroplasty are penile stricture location, the length of the stricture (>4 cm) and prior repeated endoscopic therapy attempts. Radiation-induced urethral strictures also have a worse outcome. There are various therapy options in the case of stricture recurrence after a failed urethroplasty. In the case of short stricture recurrences, direct vision urethrotomy shows success rates of approximately 60%. In cases of longer or more complex stricture recurrences, redo urethroplasty should be the therapy of choice. Success rates are higher than after urethrotomy and almost comparable to those of primary urethroplasty. Patient satisfaction after redo urethroplasty is high. Primary buccal mucosa grafting involves a certain rate of oral morbidity. In cases of a redo urethroplasty with repeated buccal mucosa grafting, oral complications are only slightly higher.

[Late consequences of urethral injuries. Reconstruction options]. / Spätfolgen von Urethraverletzungen. Rekonstruktive Möglichkeiten.

BACKGROUND: Stricture excision and posterior urethroplasty is the most common procedure after posttraumatic urethral strictures. RESULTS: Re-strictures and fistulas are treated by repeat urethroplasty. Tension-free anastomosis is prerequisite for surgical success. Urinary incontinence after posttraumatic injuries is treated by an artificial urinary sphincter.

The T-plasty: a modified YV-plasty for highly recurrent bladder neck contracture after transurethral surgery for benign hyperplasia of the prostate: clinical outcome and patient satisfaction.

OBJECTIVE: To describe a modified surgical technique for treatment of highly recurrent bladder neck contracture (BNC) after transurethral surgery for benign hyperplasia and to evaluate success rate and patient satisfaction of this novel technique. METHODS: Ten patients with highly recurrent BNC and multiple prior attempts of endoscopic treatment underwent the T-plasty. Perioperative complications were recorded and classified according to the Clavien classification. Patient reported functional outcomes were retrospectively analysed using a standardized questionnaire assessing recurrence of stenosis, incontinence, satisfaction and changes in quality of life (QoL). The questionnaires included validated IPSS and SF-8-health survey items. RESULTS: Mean age at the time of surgery was 69.2 years (range 61-79), and the mean follow-up was 26 months (range 3-46). No complications grade 3 or higher according to the Clavien classification occurred. Success rate was 100 %. No de novo stress incontinence occurred. Urinary stream was described as very strong to moderate by 80 % of the patients, mean post-operative IPSS-score was 11.3 (range 4-29), and mean post-operative IPSS-QoL was 2.4 (range 1-5). Patients satisfaction was very high or high in 90 %, and QoL improved in 90 %. The SF-8-health survey showed values comparable to the reference population. CONCLUSION: The T-plasty represents a safe and valuable option in treating highly recurrent BNC after surgery for benign hyperplasia. It offers multiple advantages compared to other techniques such as a single-staged approach and the opportunity for reconstruction of a reliable wide bladder neck by usage of two well-vascularized flaps. Success rate, low rate of complications and preservation of continence are highly encouraging.

Critical analysis of a simplified Fuhrman grading scheme for prediction of cancer specific mortality in patients with clear cell renal cell carcinoma--Impact on prognosis.

INTRODUCTION AND OBJECTIVES: The traditional 4-tiered Fuhrman grading system (FGS) is widely accepted as histopathological classification for clear cell renal cell carcinoma (ccRCC) and has shown prognostic value. As intra- and inter-observer agreement are sub-optimal, simplified 2- or 3-tiered FGSs have been proposed. We aimed to validate these simplified 2- or 3-tiered FGSs for prediction of cancer-specific mortality (CSM) in a large study population from 2 European tertiary care centers. METHODS: We identified and followed-up 2415 patients with ccRCC who underwent radical or partial nephrectomy in 2 European tertiary care centers. Univariable and multivariable analyses and prognostic accuracy analyses were performed to evaluate the ability of several simplified FGSs (i.e. grades I + II vs., grades III + IV, grades I + II vs. grade III and grade IV) to predict CSM. RESULTS: Independent predictor status in multivariate analyses was proved for the simplified 2-tiered FGS (high-grade vs. low-grade), for the simplified 3-tiered FGS (grades I + II vs. grade III and grade IV) as well as for the traditional 4-tiered FGS. The prognostic accuracy of multivariable models of 77% was identical for all tested models. Prognostic accuracy of the model without FG was 75%. CONCLUSIONS: A simplified 2- or 3-tiered FGS could predict CSM as accurate as the traditional 4-tiered FGS in a large European study population. Application of new simplified 2- or 3-tiered FGS may reduce inter-observer-variability and facilitate clinical practice without compromising the ability to predict CSM in ccRCC patients after radical or partial nephrectomy.

Management of advanced bladder cancer in the era of targeted therapies.

Systemic chemotherapy is the standard treatment of advanced and metastatic urothelial carcinoma of the bladder (UCB). Unfortunately, systemic chemotherapy is ineffective in a significant number of patients, while side effects occur frequently. Detailed molecular-genetic investigations revealed a broad heterogeneity of underlying genomic mutations in UCB and led to the detection of cancer-specific therapeutic targets. These findings may allow a more tailored and individualized patient-based therapy, focusing on specific genomic variations, which may cause chemo-resistance in patients progressing or relapsing after standard chemotherapy. Targeted therapies hold the potential to be more effective in inhibiting cancer cell growth and progression, as well as to cause fewer side effects. While targeted therapies have been successfully established in the treatment of various malignancies including renal cell carcinoma, the clinical impact of these modern treatment strategies still remains unsettled for UCB. In this review, we comprehensively summarize the most current and relevant findings on targeted therapy in advanced and metastatic UCB, elucidating chances and limitations and discussing future perspectives.

[Robot-assisted laparoscopic pyeloplasty in adults: Excellent long-term results of primary pyeloplasty]. / Roboterassistierte laparoskopische Pyeloplastik bei Erwachsenen : Exzellente Langzeitergebnisse der primären Pyeloplastik.

PURPOSE: With the development of the robot-assisted surgical technique, robot-assisted pyeloplasty (RAP) has become established as an alternative to open and laparoscopic surgery. Currently there are only a few single-center studies with larger numbers of cases and long-term results. The aim of this study was to investigate perioperative and long-term postoperative success rates of Anderson-Hynes robot-assisted pyeloplasty (RAP) at a single center. MATERIALS AND METHODS: We retrospectively reviewed our RAP experience of 61 patients performed by two surgeons between 2004 and 2013 regarding operating time, length of hospital stay, perioperative complication, and success. Overall success was measured in terms of necessary redo pyeloplasty. We also identified patients with temporary stent placement due to symptomatic hydronephrosis or with further obstruction in diuretic renography. RESULTS: Median age, operating time, and follow-up were 33 years, 195 min, and 64 months, respectively. No conversion to open procedure was necessary. The success rate was 98% (n=60) with 1 patient undergoing open redo pyeloplasty due to a recurrent stenosis. Temporary stent placement was required in 3 patients due to pyelonephritis and dilatation. CONCLUSION: Satisfying long-term success rates including low complication rates of RAP were obtained in this study. RAP presents a safe and standardized procedure for symptomatic ureteropelvic junction obstruction.

Gender-specific outcomes of bladder cancer patients: a stage-specific analysis in a contemporary, homogenous radical cystectomy cohort.

INTRODUCTION: Controversial findings regarding gender-specific oncological outcomes of urothelial carcinoma of the bladder (UCB) have recently been reported. The aim of this study was to analyze gender-specific outcomes using a stage-adjusted approach in a homogenous, contemporary radical cystectomy (RC) cohort. MATERIAL AND METHODS: We prospectively collected data of 517 UCB patients treated with RC and pelvic lymphadenectomy without neoadjuvant chemotherapy at our institution between 1996 and 2010. Stage-adjusted uni- and multivariable Cox regression models analyzed the association of gender with disease recurrence, cancer-specific mortality and overall survival. RESULTS: In total, 398 (77%) patients were male and 119 (23%) were female. Compared to men, women were more likely to have advanced tumor stages (p = 0.017), nodal metastasis (p = 0.047) and received more frequently adjuvant chemotherapy (p = 0.009). At a median follow-up of 44 months, there was no statistical difference in disease recurrence, cancer-specific mortality and overall survival between both genders when analyzed as a group. In stage-adjusted analyses, only women with non-invasive UCB were more likely to die of UCB compared to the male counterparts (p = 0.013). In gender-specific multivariable analyses that adjusted for standard clinico-pathologic features, pathologic tumor stage was an independent predictor for disease recurrence (p-values ≤0.047) and cancer-specific mortality (p-values ≤0.049), respectively. CONCLUSION: Women present with more aggressive tumor biologic features at RC, however this did not translate into inferior outcomes compared to men in stage-specific analyses in our cohort. Tumor stage is the most important factor influencing the course of disease in both genders. Validation of our findings is warranted in a larger cohort.

[Therapy of persistent or recurrent stress urinary incontinence]. / Therapieoptionen der rezidivierenden oder persistierenden Belastungsharninkontinenz.

After synthetic sling procedures, up to 16 % of women and 45.5 % of men complain about a persistent or recurrent stress urinary incontinence (SUI). Currently, randomized studies comparing the different treatment modalities of persistent or recurrent SUI are lacking. There are data of retrospective studies investigating the efficiency of synthetic slings and the artificial urinary sphincter AMS 800® in men. Synthetic slings can be applied in patients with mild SUI and without prior radiation of the pelvic region. The AMS 800® is the treatment of choice in patients with severe SUI or previous radiation.In women with persistent and recurrent SUI, the efficiency of colposuspensions, autologous and synthetic slings as well as the AMS 800® has been investigated in retrospective studies. Due to comparable cure rates and a faster postoperative recovery, synthetic slings are now superseding colposuspensions and autologous slings. Excellent success rates after AMS 800® implantation have been described for both genders; nonetheless, postoperative complications and revisions as well as the requirement of dexterity of the patients should be taken into account. Data about the efficiency of adjustable slings, the ACT® and newer artificial urinary sphincter devices like Flow-Secure® and Zephyr® ZSI 375 in the treatment of persistent and recurrent SUI is lacking.

Panurethral and complex urethral strictures. Reconstruction in several steps: current techniques and indications.

Patients with panurethral and complex urethral strictures after failed urethral reconstruction due to strictures and hypospadias repair is a rare but challenging condition. Contemporary surgical techniques include one and two staged urethroplasties using different graft substitutes (i.e., buccal mucosa) or full thickness skin grafts (i.e., from the inner thigh(, thereby providing satisfactory results with reducing the re-stricture rate in these patients. However, all current techniques do so at the expense of higher revision rates and thus requiring multiple procedures. Studies investigating the outcomes of reconstruction in panurethral and complex urethral strictures often have heterogeneous patient cohorts including children and adults, different underlying causes, and different techniques, thus allowing only limited interpretation of the published data. In the field of urethral reconstruction, where personal experience and expertise presents an accepted necessity, however, leading to rather small single center studies,only well-designed randomized clinical trials can truly answer the question of which technique will be advantageous in these patients.

[Two-stage urethral reconstruction with buccal mucosa for hypospadias cripples : Long-term results]. / Zweizeitige Harnröhrenrekonstruktion mit Mundschleimhaut bei Hypospadiekrüppeln : Langzeitergebnisse.

So-called hypospadias cripples are a challenging group of patients who present with multiple previous repair operations with unsatisfactory functional and cosmetic results. Attempts at renewed correction can be carried out with various techniques and different materials and staged repair with buccal mucosa according to Bracka has shown good results.

[Kaplan-Meier analysis in urological practice]. / Kaplan-Meier-Analysen in der urologischen Praxis.

Kaplan-Meier curves and estimates of survival are the most common way to present survival data in medicine, especially for cohorts with different lengths of follow-up. Moreover, Kaplan-Meier curves present a frequently used general graphic approach to display time-to-event outcomes. A solid understanding of how Kaplan-Meier curves are generated and how they should be analyzed and interpreted is of great importance to appraise urological literature in daily clinical practice. This article describes the basic principles of Kaplan-Meier analysis, possible variants and pitfalls. Improved knowledge of Kaplan-Meier analysis can help to improve Evidence-based urology and its application in patient care.

[Urethral reconstruction using buccal mucosa transplants]. / Harnröhrenrekonstruktion unter Verwendung von Mundschleimhauttransplantaten.

Buccal mucosa is the ideal material for urethral reconstruction because it is easy to harvest, is accustomed to permanent moisture and can be used at any location in the urethra. Stricture length and local conditions of the urethra have to be considered to decide which technique is required to reconstruct the urethra. Open urethroplasty with buccal mucosa has a success rate over 85% and should be used after unsuccessful internal urethrotomy and primarily in longer strictures.

[Urinary diversion and colon: transverse conduit and transverse pouch]. / Harnableitung und Dickdarm : Das Transversumconduit und der Transversumpouch.

In the vast majority of cases the terminal ileum is used for incontinent or continent bladder substitution. However, in irradiated patients the use of ileum segments or the ileocecal reservoir is associated with an increased risk of early and late complications. For this reason these patients should be treated with a transverse conduit or pouch as the method of choice if urinary diversion is indicated. The superior outcome of this high urinary diversion is due to the use of non-irradiated segments of the colon and ureter. The lack of experience in large bowel surgery by today's urologists should be compensated by training or referral of these high risk patients to a specialized center.

[Upper tract urothelial carcinoma. An update on clinical and pathological prognostic factors]. / Das Urothelkarzinom des oberen Harntraktes. Ein Update über klinische und pathologische prognostische Faktoren.

Upper urinary tract urothelial carcinoma (UTUC) is an uncommon but potentially lethal disease. Accurate risk stratification remains a challenge owing to the difficulty of clinical staging. Identification of risk factors may lead to individualized treatment and patient counselling and holds the potential to improve outcome. A non-systematic PubMed/Medline literature research was performed to identify and summarize clinical and pathological risk factors and urine-based markers which are associated with clinical outcome. Although knowledge of potential prognostic factors has improved over the last 5 years the overall evidence on UTUC risk factors remains limited and prospective, randomized trials are still missing. Radical nephroureterectomy is currently standard treatment for high-grade and muscle invasive UTUC. Several clinical and pathological factors (e.g. stage, grade, age, hydronephrosis, lymphovascular invasion, tumor necrosis and architecture, delay between diagnosis and surgery) were identified to be associated with outcome. Urinary cytology and fluorescence in-situ hybridization are the most commonly used urinary markers. Prospective randomized controlled trials are urgently needed to identify new risk factors and assess the efficacy. The incorporation of such prognosticators into multivariable prediction models may help to guide decision-making with regard to type of treatment, performance of lymphadenectomy and consideration of neoadjuvant or adjuvant systemic therapy.

[Management of urinary incontinence after orthotopic urinary diversion]. / Inkontinenzmanagement beim orthotopen Blasenersatz.

Orthotopic urinary diversion (OUD) is performed in almost half of all radical cystectomies. This review presents an overview of the incidence, pathophysiology, and management of urinary incontinence (UI) after OUD. Daytime and nighttime UI are reported in up to 15% and 45% of cases after OUD, respectively. UI after OUD is more frequent in women. Stress incontinence is the most common reason for daytime urinary leakage, while an absent vesicourethral reflex with reduced external sphincter muscle tone is associated with nighttime UI. Conservative management has limited therapeutic value in UI after OUD. Surgical approaches include adjustable and nonadjustable slings as well as the ProACT® system in mild stress UI. Implantation of the artificial urinary sphincter system AMS 800® is the standard treatment for stress UI after OUD. Very limited data exist regarding results after implantation of newer artificial urinary sphincter systems such as the FlowSecure® and the Zephyr® ZSI 375 after OUD.

[Advanced bladder cancer in elderly patients. Prognostic outcomes and therapeutic strategies]. / Das fortgeschrittene Urothelkarzinom der Harnblase beim älteren Patienten. Ein Überblick über Inzidenz, Prognose und therapeutische Möglichkeiten.

INTRODUCTION: Age is suggested to be the greatest single risk factor for developing urothelial carcinoma of the bladder (UCB). This review presents an overview of the incidence, prognosis, surgical and medical therapy of UCB in elderly patients (> 65 years). RESULTS: Elderly patients have an approximate 11-fold increase in the incidence and a 15-fold increase in UCB mortality when compared to younger individuals. However, adequate surgical or medical treatment is less often or delayed offered to elderly patients. In properly selected cases, similar surgical outcomes and complication rates are reported in elderly patients, regardless of the type of urinary diversion. Application of perioperative systemic chemotherapy is dependent on physiologic deterioration and comorbidities. An adequate, restrictive case selection and early proactive postoperative rehabilitation are important factors to achieve good results. CONCLUSIONS: In adequately selected elderly patients, radical cystectomy and urinary diversion as well as systemic chemotherapy are feasible, safe and efficacious treatment options for advanced UCB.

[Primary diffuse neurofibroma of the urinary bladder: a rare case report and review of the literature]. / Primäres diffuses Neurofibrom der Harnblase : Ein seltener Fallbericht und Literaturübersicht.

Diffuse neurofibromas are benign mesenchymal tumours with nerve sheath differentiation. Only a few cases have been reported in the urinary bladder. We present a well-documented case report of a 62-year-old man presenting with gross haematuria and histopathological confirmation of a diffuse neurofibroma. We further reviewed the current literature with regard to clinical features and treatment options.

[Distal stenosis of the ureter due to extrinsic endometriosis in a postmenopausal woman]. / Distale Stenose des Ureters durch extrinsische Endometriose bei einer postmenopausalen Frau.

INTRODUCTION: Endometriosis in postmenopausal women is rare, especially in the urinary tract. Only a few cases have been described. CASE REPORT: A postmenopausal woman presented with left-sided ureteric obstruction. Intraoperatively an extrinsic endometriosis was found. In contrast to other cases, the patient had no history of endometriosis or estrogen therapy. CONCLUSION: This rare disease should also be considered in female patients in non-reproductive age with symptoms of unclear hydronephrosis.