Pelvic exenteration for recurrent or advanced gynecologic malignancies - Analysis of outcome and complications.

Pelvic exenterations are known to be a last resort therapeutic option for advanced or recurrent gynecologic malignancies, which are known to have poor prognosis. All women treated with anterior (APE) or total (TPE) pelvic exenteration at our University hospital within a five-year period were identified and their data retrospectively analysed. Parameters such as demographic information, tumor type and stage, previous therapy as well as complication rate and overall survival were evaluated. 47 women were enrolled in this study. Most common indication for PE was cervical cancer (51.1%) followed by carcinoma of the vagina (17%), vulva (10.6%), endometrium (8.5%), ovaries (4.3%) and uterus (2.1%). Patients had received 1, 2 or 3 treatment modalities prior in 12.8%, 38.8% and 21.2% respectively. Predominant urinary diversion was ileum conduit (75.5%). Major complications (Clavien Dindo ≥ III) were observed in 40.4%, none in 19.2%. Early mortality was 4.3%. Median Overall Survival (mOS) was 14 months with 2- and 3-year survival rates of 38.8% and 21.2% respectively. After a median follow up of 47 months, 25.5% were still alive. Excluding patients with metastatic disease (n = 10), mOS was 20.6 months with 2- and 3-year survival rates of 46% and 35.2%. OS was significantly worse for patients with positive margins (p = 0.003). Receiving neoadjuvant treatment (25.5%) correlated with negative margins (p = 0.013) but not with overall survival. PE is feasible with acceptable complication and mortality rates. The long-time benefit is notable bearing in mind the extensive nature of the malignancies and the procedure undertaken.

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

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

[Big surprise in the lesser pelvis]. / Große Überraschung im kleinen Becken.

A 17-year-old young man presented at our clinic with asymptomatic microhematuria. Ultrasonography and computer tomography found an intraperitoneal lesion of unknown dignity located on top of the bladder. Surgical exploration and histological examination confirmed the diagnosis of a secondary pelvic spleen, a lien bipartitus.

[News with clinical relevance from major scientific meetings 2015--Update Urooncology]. / Was gab es Neues auf den Kongressen 2015?--Update Uroonkologie.

What new developments in urooncology were discussed at the 2015 annual meetings of ASCO, EAU, DGU and ESMO? This review summarises news relevant to the daily diagnosis and treatment of prostate, bladder and kidney cancer. While study results seem to change paradigms in the treatment of prostate cancer, particularly in metastatic but still hormone-sensitive stages, immunotherapeutic strategies for the treatment of kidney and urothelial cancer are very promising and might expand the systemic therapeutic options in the years to come.

Does visualisation during urethrocystoscopy provide pain relief? Results of an observational study.

BACKGROUND: To measure the effects of real-time visualisation during urethrocystoscopy on pain in patients who underwent ambulatory urethrocystoscopy. METHODS: An observational study was designed. From June 2012 to June 2013 patients who had ambulatory urethrocystoscopy participated in the study. In order to measure pain perception we used a numeric rating scale (NRS) 0 to 10. Additional data was collected including gender, reason for intervention, use of a rigid or a flexible instrument and whether the patient had had urethrocystoscopy before. RESULTS: 185 patients were evaluated. 125 patients preferred to watch their urethrocystoscopy on a real-time video screen, 60 patients did not. There was no statistically relevant difference in pain perception between those patients who watched their urethrocystoscopy on a real-time video screen and those who did not (p = 0.063). However, men who were allowed to watch their flexible urethrocystoscopy experienced significantly less pain, than those who did not (p = 0.007). No such effects could be measured for rigid urethrocystoscopy (p = 0.317). Furthermore, women experienced significantly higher levels of pain during the urethrocystoscopy than men (p = 0.032). CONCLUSIONS: Visualisation during urethrocystoscopy procedures in general does not significantly decrease pain in patients. Nevertheless, men who undergo flexible urethrocystoscopy should be offered to watch their procedure in real-time on a video screen. To make urethrocystoscopy less painful for both genders, especially for women, should be subject to further research.

[News with clinical relevance from major scientific meetings 2014 - Update Urooncology]. / Was gab es Neues auf den Kongressen 2014? - Update Uroonkologie.

What is new in urooncology in the year 2014? This review gives a brief but comprehensive overview of new developments in diagnosis and treatment of localized as well as advanced prostate, bladder and kidney cancer which have been presented on the occasion of the annual meetings of the European and American urologic and oncological associations in 2014. Attention is particularly directed to those data and results from trials which might be of direct or indirect clinical relevance.

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

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

[Metastasized renal cell carcinoma. Measurement of plasma levels of the tyrosine kinase inhibitors sunitinib, sorafenib and pazopanib]. / Metastasiertes Nierenzellkarzinom. Bestimmung der Plasmaspiegel der Tyrosinkinaseinhibitoren Sunitinib, Sorafenib und Pazopanib.

BACKGROUND: Several tyrosine kinase inhibitors (TKI) are used in the treatment of metastasized renal cell carcinoma (mRCC). This article presents a feasibility study for the measurement of plasma levels of sunitinib, sorafenib and pazopanib using liquid chromatography tandem mass spectrometry (LC-MS/MS). METHODS: A total of 23 patients suffering from mRCC under treatment with sunitinib (n=16), sorafenib (n=3) and pazopanib (n=4) were included. Plasma samples (100 µl) were separated by liquid chromatographic analysis and the plasma levels of the TKIs determined by tandem mass spectrometry. RESULTS: The plasma levels of sunitinib, sorafenib and pazopanib were measurable and the results reproducible. During storage of the plasma samples for 1 week at 4°C no significant decrease of the initial concentration was found. The highest plasma levels detected were 99 ng/ml for sunitinib, 9.8 µg/ml for sorafenib and 63 µg/ml for pazopanib. We could show variability in plasma levels according to changes in dosage of TKIs or during treatment-free intervals. CONCLUSION: Measurement of TKI plasma levels using LC-MS/MS is feasible. Further clinical studies have to be conducted to examine if there are any threshold levels for the incidence of adverse events or response to treatment.

[Update Urooncology: News with clinical relevance from major scientific meetings 2013]. / ASCO, ESMO, AUA, EAU, DGU - Update Uroonkologie - Was war klinisch relevant auf den Kongressen 2013?

What is new in urooncology in the year 2013? This review gives a brief but comprehensive overview of new developments in diagnosis and treatment of localized as well as advanced prostate, bladder and kidney cancer which have been presented on the occasion of the annual meetings of the European and American urologic and oncological associations in 2013. Attention is particularly directed to those data and results from trials which might be of direct or indirect clinical relevance.

[Predictors for presence of residual tumor in follow-up transurethral resection of bladder tumors: single center results]. / Vorhersageparameter für das Vorliegen eines Residualtumors bei der TUR-B-Nachresektion: single-center-Ergebnisse.

BACKGROUND: European Association of Urology (EAU) guidelines recommend a follow-up transurethral resection of bladder tumors (reTUR-B) for intermediate and high-risk non-muscle invasive bladder cancer (NMIBC) 2-6 weeks after the initial resection. The purpose of this study was to find parameters which indicate the presence of residual tumor in reTUR-B and to evaluate the prognostic value. PATIENTS AND METHODS: The data from all patients treated with TUR-B between January 2005 and December 2008 were retrospectively evaluated. The residual tumor rate was correlated with age, sex, staging, grading, risk group, multifocality and surgeon's level of training. RESULTS: A total number of 555 TUR-B operations were carried out and 179 patients received reTUR-B according to the EAU guidelines. Age (p=0.8), sex (p=0.7), initial staging (p=0.2), initial grading (p=0.3) and surgeon's level of training (p=0.7) did not have an impact on the rate of residual tumor in reTUR-B. Tumors categorized as high risk according to the EAU risk score in initial TUR-B (p<0.01) and multifocality (p=0.01) were associated with significantly higher rates of residual tumor. CONCLUSIONS: A reTUR-B is strongly indicated in high risk bladder tumors as well as multifocal tumors showing a significantly increased residual tumor rate. Other clinical parameters showed no prognostic value for the existence of residual tumor in reTUR-B.

[Update urooncology: news with clinical relevance from major scientific meetings 2012]. / Update Uroonkologie: Was war klinisch relevant auf den Kongressen 2012?

What is new in urooncology in the year 2012? This review gives a brief but comprehensive overview of new developments in diagnosis and treatment of localized as well as advanced prostate, bladder and kidney cancer which have been presented on the occasion of the annual meetings of the European and American urologic and oncological associations in 2012. Attention is particularly directed to those data and results of trials which might be of direct or indirect clinical relevance.

[DGFIT: Immune and targeted therapy in urologic oncology ­ what can be expected?]. / DGFIT: Immun- und Targeted Therapie in der Uroonkologie ­ was können wir erwarten?

Immune and targeted therapy represent innovative therapy options in oncology. An overview of novel immune and targeted therapy options in urologic oncology presented at the most recent scientific urological and oncological meetings is given by representatives of the German Association of Immune and Targeted Therapy (DGFIT). Besides renal cell cancer, where targeted therapy is well established, new immune and targeted approaches in prostate and bladder cancer are discussed, summarizing current results and new developments with relevant impact for the treating physician.

[Multiparametric MRI, elastography, contrastenhanced TRUS. Are there indications with reliable diagnostic advantages before prostate biopsy?]. / Multiparametrisches MRT, Elastographie, kontrastmittelverstärkter Ultraschall. Gibt es Indikationen mit verlässlichem diagnostischem Zugewinn vor Prostatastanzbiopsie?

Prostate cancer (PCA) is the most common malignancy in men with an increasing incidence and is responsible for about 11,000 deaths per year in Germany. Fortunately, the mortality of PCA has decreased in recent years despite the rising incidence reflecting improvements in diagnostic methods. Many new innovations in imaging techniques for PCA are available and may be helpful in early detection of PCA. Contrast-enhanced sonography, computer-assisted sonography, elastography and multiparametric magnetic resonance imaging (MRI) seem to be the most promising methods to increase the detection rate of PCA during diagnostic work-up. The value of these new innovative techniques concerning improvement in PCA detection is reviewed.

[Choline PET/CT in the diagnosis of primary and recurrent prostate cancer. Are there evidence-based indications?]. / Das Cholin-PET/CT in der Primär- und Rezidivdiagnostik des Prostatakarzinoms. Gibt es evidenzbasierte Indikationen?

Overdiagnosis and resulting overtreatment in prostate cancer are under intensive discussion both in the urologic communities and in the public media. Sensitive and specific diagnostic modalities could be one step forward to overcome this problem. Choline PET/CT provides fusion imaging that combines anatomical/morphological information with metabolic/functional data. Despite promising preclinical data and interesting initial clinical results, this cost-intensive and logistically demanding technology has not yet found its way into routine clinical practice; the German and European guideline recommendations are careful and reluctant. This review has the goal to give an overview of the recent data both on initial diagnosis and on staging/diagnosis for biochemical recurrence by choline PET/CT and to summarize the possible role of this innovative technology in the future, if adequate research projects can be realized.

[Update uro-oncology: scientific meetings 2011]. / ASCO, ESMO, AUA, EAU, DGU - Update Uro-Onkologie - Was gab's Neues auf den Kongressen 2011?

An overview of new development in diagnosis and treatment of prostate, bladder and renal cell cancer presented at the scientific urological and oncological meetings in 2011 is given. The special focus is on current results and new developments with clinical impact for the physician. Furthermore the authors summarize and comment scientific approaches and the most interesting research on the different fields of urological malignancies.

[Metastatic renal cell cancer in Germany in 2010. Impact of different target therapies]. / Sequenztherapie beim metastasierten Nierenzellkarzinom in Deutschland 2010. Bedeutung der verschiedenen Target-Substanzen.

BACKGROUND: Since 2006 in Germany six different target drugs for therapy in metastatic renal cell cancer (mRCC) have been used. Comparative studies for the application with the same indication are absent, and the order of potential sequential therapy is up to now unclear. The aim of the study was to collect data on therapy decisions in Germany regarding mRCC in the age of "targeted therapy". At the same time the study addressed the central question of sequencing of the different therapy options. In addition, the data of this study were to be compared to a study already published in 2008. PATIENTS AND METHODS: In 2010, four groups of doctors specialized in the therapy of patients with mRCC were asked for their behaviour in the first-, second- and third-line or sequential therapy. Those questioned included urologists in private practice (n=40), oncologists in private practice (n=40), hospital urologists (n=35) and hospital oncologists (n=35). Further the reasons for a therapy decision should be stated or weighted. RESULTS: Altogether 92% of all patients with mRCC were treated. Urologists in private practice treat only 30% of their patients themselves. The earlier used immune therapies (IFN, IL-2) no longer play a role. Sunitinib is used most often in first-line therapy by urologists in private practice (50.4%) and oncologists in private practice (47.1%). In second- and third-line therapy everolimus is used by urologists in private practice (27.1%, 26.3%) and sorafenib (28.6%) or everolimus (26.4%) by oncologists in private practice. Hospital oncologists use primarily sunitinib (56.1%), in second-line sorafenib (45.5%) and in third-line above all everolimus (19.4%). Hospital urologists use sunitinib most often for first-line therapy (57.6%) and sorafenib for second-line treatment (37.3%), while in third-line therapy temsirolimus (49.6%) and also everolimus (30.4%) were used. CONCLUSIONS: The therapy of mRCC is determined very strongly by the substances sunitinib and sorafenib. The mTOR inhibitors have recently been increasingly included in the second- and third-line therapy. With the introduction of the new targeted therapies, the treatment of these special patients is performed less by urologists and increasingly more by oncologists. This trend is strengthened in comparison to the DGFIT study from 2008.

[Pelvic lymphadenitis after total hip arthroplasty : Mimicking of lymph node metastases in a patient with prostate cancer]. / Pelvine Lymphadenitis nach Implantation einer Hüft-TEP : Imitation von Lymphknotenmetastasen im Rahmen einer radikalen Prostatektomie.

This report describes the case of a 65-year-old patient who underwent radical prostatectomy in our department. Intraoperatively we detected suspicious lymph nodes on the left side. The histopathological examination revealed histiocytosis and foreign body giant cells but no sign of tumor. The enlarged lymph nodes were ascribed to an ipsilateral total hip arthroplasty performed 14 years previously because of progressive coxarthrosis. Lymphadenitis after total hip arthroplasty is frequently observed. Histopathologically and with the use of polarized light microscopy, histiocytosis and wear particles such as titanium, polyethylene, and polyethylene-methylacrylate may be detected. When operating on patients with arthroplasty of a lower limb, particularly those with a total endoprosthesis, the surgeon should bear in mind that changes in lymph node consistency and size do not necessarily indicate tumor involvement or metastases.

[Effects of botulinum toxin type A in the single and repeated treatment of overactive bladder. A prospective analysis]. / Wirkung von Botulinumtoxin A in der ein- und mehrmaligen Behandlung der überaktiven Blase. Eine prospektive Analyse.

BACKGROUND: Quality of life (QoL) is negatively affected by the symptoms of overactive bladder (OAB). Standard treatment is the administration of anticholinergics, which are associated with nasty adverse effects. The aim of this prospective study was to evaluate the efficacy of singular and repeated botulinum-A toxin (BTX-A) injections in the bladder detrusor muscle in patients suffering nonneurogenetic OAB. RESULTS: Forty patients with OAB were treated with 500 mouse units of BTX-A (Dysport). Subjective satisfaction, micturition data, side effects, and the duration of effect were evaluated prospectively. The median follow-up was 9 months. The mean daily frequency decreased in 81% (p<0.001) of the patients, and nocturia decreased in 68% (p=0.009). The mean duration of effect until recurrence of OAB symptoms was 6 months. Using a visual analogue scale, subjective improvement in QoL was achieved in 83% of patients. Except for temporary urine retention in four cases, no severe side effects occurred. CONCLUSION: The results of our prospective study show that the endoscopic application of BTX-A is a safe and highly effective treatment option for patients with OAB refractory to conventional treatment.

[Impact of immunotherapy in metastatic kidney cancer in Germany after introduction of new target therapy--results of a telephone survey of the German Society of Immuno- and Targeted Therapy (DGFIT)]. / Welche Bedeutung hat die Immuntherapie beim metastasierten Nierenzell-karzinom nach Einführung der neuen Target-Substanzen in Deutschland--Ergebnisse einer repräsentativen Umfrage der DGFIT.

INTRODUCTION: Until recently, the standard therapy for metastatic renal cell carcinoma (mRCC) in Germany consisted of interleukin-2 (IL-2), interferon-alfa (IFN) as single agents or in combination, with or without chemotherapy. Since 2005, new drugs (target drugs) in the therapy for mRCC are available. The aim of this study was to analyse the current therapy standard in Germany. METHODS: By representative telephone interviews (GFK-Nürnberg by order of DGFIT) the following colleagues were contacted A: urologists in private practice (n = 40), B: oncologists in private practice (n = 40), C: hospital urologists (n = 35) and D: hospital oncologists (n = 35). Screening criteria were 1) responsibility for therapy in mRCC; 2) therapy of at least 10 patients with mRCC per year. RESULTS: Patients/year: A: n = 19, B: n = 17, C: n = 43, D: n = 21. 98% of patients with mRCC were treated: A: the most frequent therapy was sunitinib (43%, 42%, 33% as first-, second-, third-line), B: the most frequent therapy was sunitinib (45% as first-line, 37% as second-line), the most frequent third-line therapy was sorafenib (35%); C: the most frequent therapy were sorafenib and sunitinib (first-line 26% vs. 27%, second-line 46% vs. 42%), in third-line therapy additionally temsirolimus 24%; D: primary sorafenib and sunitinib (first-line 33% vs. 40%, second-line 46% vs. 42%), in third-line therapy additionally temsirolimus 23%. Immunotherapy (IL-2, IFN with or without chemotherapy) in mRCC plays in Germany for the second- and third-line therapy in A-D no major role (less than 10%). Otherwise, for first-line therapy immunotherapy has some relevance: A: 25%, B: 37%, C: 33%, D: 16%. The most important criteria for therapy decision making in A-D were: efficacy, toxicity, drug approval status. CONCLUSIONS: Most patients with mRCC in Germany were seen by hospital urologists. Sunitinib (in first-line) and sorafenib (in second-line) are currently the most frequent prescribed drugs in mRCC. Temsirolimus is used mostly for third-line therapy (followed by sunitinib/sorafenib). Treatment of mRCC in Germany is increasingly being performed by oncologists.