[Quality criteria in urology : How to obtain comparable results?] / Qualitätskriterien in der Urologie : Wie kann eine Vergleichbarkeit der Ergebnisse geschaffen werden?

The standardization of procedural flow and medical documentation increasingly allows further possibilities. The best-known example of process standardization is the centralized treatment of complex clinical pictures, while patient-reported outcome measurements (PROMs) enable standardized documentation. Using the example of prostate cancer, existing literature on the topic of quality optimization in medicine is discussed. The following key points are addressed: (1) Increasing use of standardized PROMs for outcome documentation. (2) The transfer of complex clinical pictures to dedicated specialized centers has been shown to increase the quality of patient care as long as standardized PROMs are used. (3) Healthcare policymakers benefit from the use of PROMs and increasingly pursue a "value-based healthcare" approach.

[Systematic analysis of treatment results as a quality control instrument using the example of a large European center]. / Systematische Ergebnisanalyse als Qualitätsinstrument am Beispiel des größten europäischen Zentrums.

BACKGROUND: Measurement of the quality of treatment has become increasingly important in hospitals. An easy and practical solution in data acquisition is the Patient-Reported Outcome Measurement (PROM). METHODS: In this article the historical development, general conditions, and difficulties of using the outcome measurement in our patients are describe. In addition, we illustrate the wide range of benefits due to our survey. Based on data from 2008-2013, the functional and oncological results of treatment in our clinic are shown. The main focus lies on the PROMs, e.g., urinary continence evaluated with the daily pad use, sexual function with the IIEF-5 questionnaire, and postoperative complications. CONCLUSIONS: A systematic and standardized outcome measurement may help to improve the quality of treatment, provides factual information for patients, and supports medical development.

["Expanded prostate cancer index composite" (EPIC-26): Results of functional treatment in patients with localized prostate cancer]. / "Expanded prostate cancer index composite" (EPIC-26) : Funktionelles Behandlungsergebnis bei Patienten mit lokalisiertem Prostatakarzinom.

The standardized collation of the quality of treatment is a subject of discussion both nationally and internationally. This article presents the work of the International Consortium for Health Outcomes Measurement (ICHOM) and the validated German translation of the expanded prostate cancer index composite (EPIC-26). This questionnaire allows a standardized interdisciplinary collation of the quality of treatment for all therapy modalities of localized prostate cancer. Use of the ICHOM standard set and the EPIC-26 achieves a possibility for comparison of each form of therapy with respect to the curative success and the effect on health and quality of life of patients.

Adherence of the indication to European Association of Urology guideline recommended pelvic lymph node dissection at a high-volume center: Differences between open and robot-assisted radical prostatectomy.

PURPOSE: Contemporary adherence of the indication to European Association of Urology (EAU) guideline recommendation for pelvic lymph node dissection (PLND) at either open (ORP) or robot-assisted radical prostatectomy (RARP) at a high-volume center is unknown. To assess guideline recommended and observed PLND rates in a high-volume center cohort. METHODS: We relied on the Martini-Clinic database and focused on patients treated with either ORP or RARP, between 2010 and 2013. Actual performed PLND was compared to European Association of Urology (EAU) guideline recommendation defined by nomogram predicted risk of lymph node invasion >5%. Categorical and multivariable logistic regression analyses targeted two endpoints: 1) probability of guideline recommended PLND and 2) probability of no PLND, when not recommended by EAU guideline. RESULTS: Within 7868 PCa patients, adherence to EAU PLND guideline recommendation was 97.1% at ORP and 96.8% at RARP (p = 0.7). When PLND was not recommended, it was more frequently performed at RARP (71.6%) than at ORP (66.2%) (p = 0.002). Gleason score, PSA and number of positive biopsy cores were independent predictors for both either PLND when recommended, or no PLND when not recommended (all p < 0.05). Clinical tumor stage, age and surgical approach were also independent predictors for no PLND when not recommended (all p < 0.05). CONCLUSIONS: Adherence of the indication to EAU guideline recommended PLND is high at this high-volume center. Neither ORP nor RARP represent a barrier for PLND, when recommended. However, a high number of patients underwent PLND despite absence of guideline recommendation. Possible staging advantages and PLND related complications needs to be individually considered, especially, when LNI risk is low.

[DaVinci robot-assisted laparoscopic prostatectomy: benefit for obese men? - A matched-pair analysis]. / Roboterassistierte radikale Prostatektomie : Vorteil bei adipösen Männern? - Eine Matched-pair-Analyse.

BACKGROUND: Open radical retropubic prostatectomy (RRP) in obese patients (BMI ≥30) is associated with increased perioperative morbidity. The aim of the study was to evaluate the possible benefit of DaVinci robotic-assisted laparoscopic prostatectomy (RARP) compared to RRP in obese patients. PATIENTS AND METHODS: We identified 255 patients with a localized prostate cancer (PCa) and BMI ≥30 treated with radical prostatectomy from January 2009 to December 2011. To adjust for risk factors of increased perioperative morbidity (nerve-sparing, pelvic lymph node dissection, prostate volume), a propensity score-based matching was performed between RRP and RARP (n=115 each group). Both groups were compared by taking into consideration histopathological outcomes as well as peri- and postoperative (30 days) morbidity. RESULTS: There were no differences in histopathological characteristics (pT/pN-stage, Gleason score, R-stage; all p>0.05) in both groups. Mean blood loss (276 ml vs. 937 ml), transfusion rate (0.9% vs. 8.7%) and 30-day complications according to the Clavien classification system (Clavien ≥ 2; 9.5% vs. 22.6%) were decreased in RARP (all p<0.05). In a multivariate logistic regression model, RARP vs. RRP was associated with a significantly reduced risk of a Clavien ≥ 2 complication during follow-up (OR 0.3; p= 0.0047). Recovery of continence was significantly better for RARP patients after 3 months (p= 0.02). There was no difference in erectile function 12 months postoperatively. CONCLUSION: Our findings of decreased transfusion and complication rates and a trend of better early recovery of continence in RARP should be considered in obese patients (BMI >30) scheduled for radical prostatectomy.

High Nr-CAM expression is associated with favorable phenotype and late PSA recurrence in prostate cancer treated by prostatectomy.

BACKGROUND: Neuron-glia-related cell-adhesion molecule (Nr-CAM) is another potential membrane-bound target molecule for specific prostate cancer therapy. The role of Nr-CAM in normal and neoplastic prostate tissue has not been extensively studied. The aim of our study is to evaluate the prevalence of Nr-CAM expression in prostate cancer and to explore its association with phenotype and clinical disease course. METHODS: A preexisting tissue microarray including more than 3000 prostate cancers that underwent prostatectomy at our center with clinical follow-up data was used. The tissue microarray (TMA) was immunhistochemically stained for Nr-CAM. RESULTS: A total of 2883 (88.4%) of tumor samples were interpretable in our TMA analysis. Membranous Nr-CAM staining was seen in 1418 (49.2%) of 2883 analyzable cases. According to predefined criteria, staining was considered weak in 778 (27.0%), moderate in 412 (14.3%) and strong in 228 (7.9%) cancers. Significant associations were found with pathological tumor stage (P=0.0015), Gleason grade (P=0.0003), nodal stage (P=0.0061), preoperative PSA (P=0.0138) and prolonged PSA recurrence-free survival (P<0.0001). CONCLUSIONS: Nr-CAM expression is frequent in prostate cancer. High level of Nr-CAM expression is associated with favorable tumor phenotype and reduced risk of PSA recurrence. The abundant presence of Nr-CAM in prostate cancer epithelium makes Nr-CAM a potential target of therapy.

Influence of low-molecular-weight heparin dosage on red blood cell transfusion, lymphocele rate and drainage duration after open radical prostatectomy.

BACKGROUND: To assess the rates of red blood cell (RBC) transfusions, pelvic lymphoceles, and prolonged drainage duration in patients after radical prostatectomy (RP) receiving perioperative bridging with low-molecular-weight heparin (LMWH). PATIENTS AND METHODS: Between 2006 and 2009, 114 RP patients receiving bridging therapy with 60 mg (n = 63) or ≥80 mg (n = 51) Enoxaparin/d were compared to 1327 consecutive RP patients receiving 40 mg Enoxaparin/d. Logistic regression models were used to test the effect of LMWH dosage on all three outcomes. Covariables included age, body mass index (BMI), Charlson comorbidity index (CCI), prostate volume, pelvic lymph node dissection, and pathological stage. RESULTS: The RBC transfusion rates in patients treated with 40, 60 and ≥80 mg were 4.9, 9.5 and 19.6%, respectively (p < 0.001). The respective lymphocele rates were 6.4, 3.2 and 2.0% (p = 0.26). The respective rates of drainage duration of ≥4 days were 6.7, 4.8 and 16.7% (p = 0.088). After adjusting for confounding factors, patients receiving ≥80 mg were 4.1-fold more likely to be transfused than patients receiving prophylactic LMWH (p = 0.02). Similarly, patients receiving ≥80 mg were 3.2-fold more likely to have a drainage duration of ≥4 days than patients receiving prophylactic LMWH (p = 0.03). CONCLUSIONS: Patients with a perioperative bridging with LMWH in RP are more likely to receive a RBC transfusion and to have prolonged drainage duration. Conversely, bridging therapy was not associated with an increased risk of lymphocele formation.

Prognostic relevance of Bcl-2 overexpression in surgically treated prostate cancer is not caused by increased copy number or translocation of the gene.

BACKGROUND: Overexpression of anti-apoptotic Bcl-2 plays a role in prostate cancer progression, particularly in transformation to androgen-independent disease. Androgen-independent prostate cancers have been shown to harbor Bcl-2 gene copy number gains frequently suggesting that this genetic alteration might play a role in Bcl-2 overexpression. The relation of Bcl-2 overexpression and copy number gains or translocation of the BCL-2 gene in prostate cancer under hormone-naïve conditions is unknown. METHODS: Prostate cancers of 3,261 hormone-naïve patients undergoing radical prostatectomy were arrayed in a TMA with one tissue core (diameter 0.6 mm) per tumor. Bcl-2 immunohistochemistry, analyzed for Bcl-2 expression level (negative, low, and high), was correlated with clinical, histopathological and molecular (Ki67, p53) tumor features, and biochemical failure. Cancers with high-level Bcl-2 expression were evaluated for genetic aberrations by fluorescence in situ hybridization (FISH). RESULTS: Bcl-2 expression was significantly up-regulated in tumors with aggressive phenotype as indicated by high Gleason score (P < 0.0001), advanced stage (P < 0.0001), and high proliferation index (P = 0.0114). The different Bcl-2 expression levels translated into significantly different survival curves showing better outcome for patients with lower Bcl-2 levels. The prognostic information obtained from the anti-apoptotic Bcl-2 was independent from the proliferation index (Ki67) of the cancer. FISH analysis detected no copy number gains or translocation of the Bcl-2 gene. CONCLUSION: Bcl-2 overexpression in prostate cancers under hormone-naïve conditions is not associated with increased copy numbers of the gene. This suggests that these frequently detected genetic alterations in androgen-independent tumors occur late in prostate cancer progression.

MR Imaging of Prostate Cancer: Diffusion Weighted Imaging and (3D) Hydrogen 1 (H) MR Spectroscopy in Comparison with Histology.

UNLABELLED: Purpose. To evaluate retrospectively the impact of diffusion weighted imaging (DWI) and (3D) hydrogen 1 ((1)H) MR-spectroscopy (MRS) on the detection of prostatic cancer in comparison to histological examinations. MATERIALS AND METHODS: 50 patients with suspicion of prostate cancer underwent a MRI examination at a 1.5T scanner. The prostate was divided into sextants. Regions of interest were placed in each sextant to evaluate the apparent diffusion coefficient (ADC)-values. The results of the DWI as well as MRS were compared retrospectively with the findings of the histological examination. Sensitivity and specificity of ADC and metabolic ratio (MET)-both separately and in combination-for identification of tumor tissue was computed for variable discrimination thresholds to evaluate its receiver operator characteristic (ROC). An association between ADC, MET and Gleason score was tested by the non-parametric Spearman ρ-test. Results. The average ADC-value was 1.65 ± 0.32mm(2)/s × 10(-3) in normal tissue and 0.96±0.24 mm(2)/s × 10(-3) in tumor tissue (mean ± 1 SD). MET was 0.418 ± 0.431 in normal tissue and 2.010 ± 1.649 in tumor tissue. The area under the ROC curve was 0.966 (95%-confidence interval 0.941-0.991) and 0.943 (0.918-0.968) for DWI and MRS, respectively. There was a highly significant negative correlation between ADC-value and the Gleason score in the tumor-positive tissue probes (n = 62, ρ = -0.405, P = .001). MRS did not show a significant correlation with the Gleason score (ρ = 0.117, P = .366). By using both the DWI and MRS, the regression model provided sensitivity and specificity for detection of tumor of 91.9% and 98.3%, respectively. Conclusion. The results of our study showed that both DWI and MRS should be considered as an additional and complementary tool to the T2-weighted MRI for detecting prostate cancer.

[Type and extent of preoperative imaging before radical prostatectomy]. / Evaluation von Art und Ausmass der präoperativen Bildgebung vor radikaler Prostatektomie.

BACKGROUND: According to current guidelines, in cases of newly diagnosed prostate cancer the type and extent of imaging to be performed should be based on the patient's risk profile. We investigated the rate of computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy carried out before radical prostatectomy (RP) depending on the individual risk profile. PATIENTS AND METHOD: Between 1 January 2006 and 31 December 2007, a total of 1,018 consecutive patients who had not received neoadjuvant hormone therapy were treated with RP in our department. We determined the preoperative rates of CT, MRI, and bone scintigraphy by reviewing the medical charts. The patients were stratified according to the D'Amico criteria into low-risk, intermediate-risk, and high-risk groups. RESULTS: Of the 1,018 subjects, 493 (48%) were classified as low-risk, 403 (40%) as intermediate-risk, and 122 (12%) as high-risk patients, respectively. The rate of preoperative abdominal CT/MRI and bone scintigraphy was 17 and 23% in the low-risk group, 25 and 39% in the intermediate-risk patients, and 39 and 57% in the high-risk group. CONCLUSION: The rate of preoperative CT and bone scintigraphy is extremely high in the low-risk group. In contrast the rate in the high-risk patients more likely appears to be too low. The discrepancy between the rates of preoperative imaging subject to the patient's risk profile shows that precisely formulated guidelines addressing this issue are needed.

Depression, anxiety, post-traumatic stress disorder and health-related quality of life and its association with social support in ambulatory prostate cancer patients.

The aim of this study is to identify anxiety, depression and post-traumatic stress disorder in prostate cancer patients and to investigate the association with social support and health-related quality of life. A total of 511 men who had undergone prostatectomy were surveyed during ambulatory follow-up care for an average of 27 months after surgery using standardised self-report measures (e.g. Hospital Anxiety and Depression Scale, Posttraumatic Stress Disorder Checklist--Civilian Version, Illness-Specific Social Support Scale, Short-Form Health Survey). Seventy-six per cent of patients evaluated their disease as 'not' or a 'little threatening'. The cancer diagnosis and uncertainty were most frequently reported as 'distressing', while medical treatment and doctor-patient interaction were most frequently evaluated as 'most helpful'. The number of patients reporting increased levels of psychological distress was 16%, with 6% demonstrating signs of having severe mental health problems'. No higher levels of anxiety and depression were observed in cancer patients compared with age-adjusted normative comparison groups. Lack of positive support, detrimental interactions and perceived threat of cancer were found to be predictors of psychological co-morbidity (P < 0.001). Lack of positive support, detrimental interactions, threat of cancer, disease stage and age significantly predicted mental health (P < 0.001), whereas the impact of social support on physical health was rather weak. Findings emphasise the need for routine psychosocial screening.

Activating BRAF gene mutations are uncommon in hormone refractory prostate cancer in Caucasian patients.

Activating mutations in the cytosolic serine/threonine kinase, BRAF, have been reported in a variety of neoplasms. BRAF activation may contribute to tumor growth via activation of the MAP/ERK kinase pathway, and BRAF represents a possible therapeutic target. Activating BRAF mutations were recently reported in approximately 10% of prostate cancer cases in Asian patients. In the present study, 43 hormone refractory prostate cancers were analyzed for BRAF mutations in order to determine whether anti-BRAF therapy is a suitable approach for advanced prostate cancer patients. In all of the studied tumors, BRAF exons 11 and 15 were PCR-amplified and sequenced, including the backward and forward sequences. BRAF mutations were noted only in the positive control tissues, but were not found in any of the 43 analyzed prostate cancers. We conclude that BRAF mutations occur only rarely in prostate cancers in Caucasian patients and are not associated with tumor progression. The application of anti-BRAF therapies may therefore not be beneficial for prostate cancer.

[F(18)]-fluoroethylcholine combined in-line PET-CT scan for detection of lymph-node metastasis in high risk prostate cancer patients prior to radical prostatectomy: Preliminary results from a prospective histology-based study.

PURPOSE: To evaluate the diagnostic potential of PET/CT using ([F(18)]fluorethylcholine (FEC) for lymph node (LN) staging in high risk prostate cancer (PCa) patients prior to radical prostatectomy (RP). PATIENTS AND METHODS: Twenty patients with localised PCa and > or =20% LN risk according to a published nomogram were prospectively enrolled. FEC PET/CT was done minimum 14 d after prostate biopsy. Afterwards, open RP and extended pelvic LN dissection (ePLND) were performed. Clinical stage, Prostate Specific Antigen (PSA) and biopsy Gleason Grading were assessed and histopathological evaluation of the RP-specimens and dissected LN has been performed. The results from PET/CT were compared with LN metastasis according to their anatomical site. RESULTS: Overall, 285 LN have been removed with a mean number of 15 nodes per patient (7-26). Of the 20 patients, 9 men were LN positive (45%), which corresponds to 31 positive LN with a mean size of 7 mm (0.8-12 mm). Dissection of the obturator fossa, external iliac artery/vein and internal iliac artery/vein revealed 36%, 48% and 16% of positive LN, respectively. FEC PET/CT did not detect one single positive LN, thus was false-negative in 31 metastasis and true negative in 254 LN. CONCLUSION: Based on our results which confirmed experience from the previous studies, FEC PET/CT scan did not prove to be useful for LN staging in localised PCa prior to treatment and should thus not be applied if clinically occult metastatic disease is suspected.

[The value of real-time elastography in the diagnosis of prostate cancer]. / Die Wertigkeit der Echtzeitelastographie in der Diagnostik des Prostatakarzinoms.

Randomized biopsy sampling under transrectal ultrasound (TRUS) guidance is the gold standard for the diagnosis of prostate cancer. In addition improvements in the quality of conventional ultrasound, new methods that complement conventional TRUS are opening the door to earlier and better targeted diagnosis of prostate cancer. One of these new methods is sonoelastography. Its impact on prostate cancer diagnostics has not yet been fully investigated, but the number of publications on this new technique indicate increasing interest in it.

Partin Tables cannot accurately predict the pathological stage at radical prostatectomy.

PURPOSE: The Partin Tables represent the most commonly used staging tool for radical prostatectomy (RP) candidates. The Partin Tables' predictions are used to guide the type (nerve preserving RP) and/or the extent (RP with wide resection) of RP. We examined the ability of the Partin Tables' predictions incorrectly assigning the stage at RP. METHODS: The testing of the Partin Tables (external validation) was based on 3105 patients treated with RP at a single European institution. Standard validation metrics were used (area under the receiver operating characteristics curve, AUC) to test the three endpoints predicted by the Partin Tables, namely the presence of extracapsular extension (ECE), seminal vesicle invasion (SVI), and lymph node invasion (LNI). RESULTS: Ideal predictions are denoted with 100% accuracy vs. 50% for entirely random predictions. For the 2001 version of the Tables the accuracy defined by the AUC was 79.7, 77.8, and 73.0 for ECE, SVI, and LNI, respectively. For the 2007 version of the Tables the corresponding accuracy estimates were 79.8, 80.5, and 76.2. The relationship between predicted probabilities and observed rates was poor. CONCLUSION: The Partin Tables are meant to guide clinicians about the safety of nerve bundle preservation at RP, about the need for seminal vesicle resection or for lymphadenectomy. Therefore, the use of the Partin Tables predictions may significantly affect the type and/or the extent of RP. In their present format the Partin Tables are not accurate enough to influence the pre-operative decision making regarding the type or extent of RP.

[Role of lymph node dissection in prostate cancer]. / Stellenwert der Lymphadenektomie beim Prostatakarzinom.

We present a comprehensive literature review and critical discussion of the diagnostic and therapeutic value of lymph node dissection in prostate cancer. Lymph node dissection is currently the most reliable staging procedure for detecting lymph node metastases in prostate cancer. Accuracy increases with the extent of the procedure. Overall, in patients with positive lymph nodes after radical prostatectomy and lymph node dissection, a favorable long-time cancer-specific survival can be observed. These data seem to be independent of the extent of the lymph node dissection and also independent of the administration of adjuvant therapy. It can be suspected that patients with lymph node metastases present different prognostic groups based on the extent of lymph node involvement. However, these risk groups might reflect only a lead-time bias, so the therapeutic value of lymph node dissection remains unclear. In conclusion, the therapeutic value of lymph node dissection in prostate cancer must be sufficiently evaluated in prospective clinical trials. Each patient should be individually counseled regarding his individual tumor features and the use of statistical prognostic tools such as nomograms.

[Is rehabilitation of erectile function following pelvic surgery reasonable? Review of the literature: from sports to PDE5 inhibitors]. / Ist eine Rehabilitation der erektilen Funktion nach beckenchirurgischen Eingriffen sinnvoll? Literaturübersicht vom Sport bis zur PDE-5-Inhibitoren-Gabe.

Increasingly, urologists are seeing patients with erectile dysfunction after pelvic operations. In most cases, radical prostatectomy is the cause. Even when a nerve-sparing procedure is performed, approximately 50% of the patients suffer from erectile dysfunction. This report discusses the causes and theoretical therapies, including lifestyle changes, strategies for neuroregeneration and the associated prevention of apoptosis of the smooth muscle of the corpus cavernosum and improvement of the corpora cavernosa by increased oxygenation. According to the international literature, many of these agents and lifestyle modifications display promise for treating impotence. Early treatment for patients recovering from pelvic operations seems to be reasonable. It is assumed that the natural recovery of erections may take as long as 18 to 24 months postsurgery or even longer; however, treatment modalities may reduce the time to erectile recovery.

[Comparison of the effectiveness between long-term instillation of mitomycin C and short-term prophylaxis with MMC or bacille Calmette-Guérin. Study of patients with non-muscle-invasive urothelial cancer of the urinary bladder]. / Vergleich der Effektivität der Langzeitinstillation mit Mitomycin C gegen Kurzzeitprophylaxen mit MMC oder Bacillus Calmette-Guerin. Untersuchung bei Patienten mit nicht muskelinvasivem Urothelkarzinom der Harnblase.

BACKGROUND: Adjuvant instillation therapy with chemo- or immunotherapeutic agents is an integral component in the treatment of non-muscle-invasive bladder cancer. There is, however, no general consensus on the choice of medication and the optimal duration of therapy. This multicenter trial compared a long-term treatment regimen with mitomycin C (MMC) with two short-term treatment approaches with MMC or bacille Calmette-Guérin (BCG) for intermediate-/high-risk bladder tumor after transurethral resection. In patients with low-risk bladder tumors, the effectiveness of six weekly MMC instillations was determined and compared with the results of patients not receiving adjuvant treatment. MATERIAL AND METHODS: A total of 495 patients with intermediate-/high-risk bladder tumor (recurrent and/or multifocal pTaG1, pTaG2-3, or pT1G1-3) were randomly administered either BCG-RIVM 2x108 CFU in six weekly instillations, MMC 20 mg in six weekly instillations, or MMC 20 mg in six weekly instillations with subsequent monthly instillations for 3 years. A total of 132 low-risk patients (first diagnosis of a unifocal pTaG1 bladder tumor) were randomly allocated to two treatment arms. In the first arm, 20 mg MMC were instilled weekly six times. In the control arm, the patients received no adjuvant therapy. RESULTS: The 3-year recurrence-free rate in the patients of the intermediate-/high-risk group was 65.5% (95% CI: 55.9-73.5%) in the BCG arm and 68.6% (95% CI: 59.9-75.7%) in the MMC short-term arm. In the MMC long-term arm, the 3-year recurrence-free rate was significantly higher at 86.1% (95% CI: 77.9-91.4%, log-rank test: p=0.001). There was no increased toxicity observed with long-term administration of MMC. In the low-risk group, the 3-year recurrence-free rate after adjuvant therapy was 74% (95% CI: 60.0-83.8%) and in the patients receiving no adjuvant treatment 63% (95% CI: 46.6-75.5%, corresponding to a hazard ratio of 0.58 (95% CI: 0.28-1.18%). The difference between the treatment arms was not significant. CONCLUSION: Long-term prophylaxis with MMC results in a significantly reduced recurrence rate in intermediate-/high-risk bladder cancer with a comparable toxicity profile in comparison to short-term MMC or short-term BCG. Our study showed no significant decrease of the recurrence rate in low-risk tumors with six adjuvant MMC instillations. This treatment approach thus does not represent an alternative to early instillation.

[Active surveillance for prostate cancer]. / Aktive Uberwachung des Prostatakarzinoms.

Active surveillance is a valuable treatment option in patients with newly diagnosed low-risk prostate cancer. Studies considering a watchful waiting approach showed favourable cancer-specific survival rates in such patients and it is assumed that patients benefit from a definitive therapy if life expectancy exceeds 10-15 years. Therefore active surveillance is especially valuable in older men and in patients with an elevated comorbidity profile. Precise identification of histologically and clinically insignificant prostate cancers is still not possible today. Active surveillance includes regular PSA measurements combined with follow-up biopsies; however, no standardized protocol exists so far. Histological progression in the follow-up biopsy and PSA elevation are the most important criteria for initiating definitive therapy. Today only a minority of low-risk patients join an active surveillance protocol and a substantial proportion of these men leave such a protocol early without evidence of progression. The psychological burden of living with an untreated cancer seems to be responsible for this. Active surveillance has the potential to lead to undertreatment as there is some evidence that prolonged treatment delay might adversely affect outcome of definitive therapy.