[Treatment of staghorn calculi. Strategies and results of the combined use of new technics]. / Die Behandlung des Ausgusssteines. Strategien und Ergebnisse des kombinierten Einsatzes neuer Techniken.

From January 1984 to June 1986, 270 patients with staghorn calculi were treated by ESWL, PCNL, or a combination of both. The indications were determined according to stone burden, distribution of stone load, architecture of the renal collecting system, radiopacity, and chemical composition of the calculi. Another group (83 patients) treated from January 1982 to October 1983 exclusively with open surgery was also examined. In a retrospective study, the treatment and follow-up data of the two groups were evaluated and compared. At discharge, 78 (29%) of the patients treated by the new techniques were free of stones, while 192 (71%) still had residual fragments in the kidney or in the ureter. Among the group treated by open surgery, 54 (65.1%) were free of stones at discharge, 17 (20.4%) still had residual fragments, and 12 (14.5%) had to undergo nephrectomy. The follow-up data (18 months n = 186) for the ESWL-PCNL-group revealed a stone-free rate of 54.8%. Residual fragments were observed in 40.3% and recurrent stone formation occurred in only 4.9%. Follow-up examination of group treated by open surgery (42 months, n = 61) revealed a stone-free rate of 72.1%, while residual stones persisted in 8.2% and recurrent stone formation occurred in 19.7%. The incidence of urinary tract infection was only 11.3% after ESWL/PCNL, as against 30% after open surgery. It is remarkable that 80% of the patients with residual fragments after ESWL-PCNL did not have any such symptoms as infection or colic.

[Polychemotherapy using the M-VEC protocol (methotrexate, vinblastine, epirubicin, cisplatin) in advanced urinary bladder cancer--effectiveness and toxicity]. / Polychemotherapie nach dem M-VEC Schema (Methotrexat, Vinblastin, Epirubicin, Cisplatin) beim fortgeschrittenen Harnblasenkarzinom--Effektivität und Toxizität.

We report on preliminary experience with a modified M-VAC (methotrexate, vinblastine, adriamycin and cisplatin) regimen in which adriamycin was replaced by the less toxic 4-epirubicin at equal doses (M-VEC). This study includes 58 patients suffering from advanced bladder cancer, with a minimum observation time of 12 months; each patient received at least two courses of M-VEC (mean follow-up 22 months, average 3.9 cycles). Most (22; 37.9%) of the tumors were T3-4 NO MO; 20 (34.4%) were T3-4 N1-2 MO; and 16 (27.7%) were T3-4 NO-2 M1. Microscopically, 52 (89.6%) were pure transitional cell carcinoma, 5 were (8.6%) squamous cell/carcinomatous transformation; 1 (1.8%) sarcoma was found. Chemotherapy was given as palliative treatment in 34 (58.6%) patients, as neo-adjuvant therapy in 19 (32.8%) cases and as adjuvant therapy in 5 (8.6%) patients. The overall response rate was 72.3% (CR = 51.7%), with a mean duration of response of 18+ months. The disease-free survival so far amounts to 24/58 (41.4%). Squamous cell carcinoma does not respond to M-VEC. Locally advanced bladder cancer (T3-4 NO-2 MO) responds significantly better than metastatic (M1) disease (78.5% vs 56.2%), resulting in an increased survival rate (57% versus 12.5%) after 22 months. The toxicity of M-VEC is considerably lower than has been reported for other regimens (M-VAC, CMV, CM). The toxic effects included mucositis (3%), nadir sepsis (2.4%) and drug-related death (2.4%).

[Gemcitabine/cisplatin vs. MVAC. 5 year survival outcome of the phase III study of chemotherapy of advanced urothelial carcinoma in Germany]. / Gemcitabin/Cisplatin vs. MVAC. 5-Jahres-Ergebnisse der Phase-III-Studie zur Chemotherapie des fortgeschrittenen Urothelkarzinoms in Deutschland.

Of 405 patients with stage IV transitional cell carcinoma from an international multicenter phase III trial, 70 were randomized in Germany to receive either gemcitabine/cisplatin or standard MVAC systemic chemotherapy for locally advanced or metastatic urothelial cancer. Overall survival as the primary endpoint of the study was similar in both arms (median survival GC 15.4 months vs MVAC 16.1 months), as were tumor-specific survival and time to progressive disease. In the intent-to-treat analysis, the 5-year overall survival rate was 10% for patients randomized to GC and 18% randomized to MVAC. Tumor overall response rates (GC 54%, MVAC 53%) were similar. The toxic death rate was 0% in the GC arm and 3% (one patient) in the MVAC arm. Significantly more GC than MVAC patients experienced grade 3/4 anemia (GC 52%, MVAC 20%) with significantly more red blood cell transfusions in the GC arm.Significantly more GC than MVAC patients had grade 3/4 thrombocytopenia (GC 54%, MVAC 17%) without grade 3/4 hemorrhage or hematuria in either arm. More MVAC patients experienced grade 3/4 neutropenia (GC 56%, MVAC 61%, p=1.000), neutropenic or leukopenic fever (GC 0%, MVAC 10%, p=0.237), mucositis (GC 0%, MVAC 7%, p=0.495), and alopecia (GC 6%, MVAC 36%, p=0.004). GC represents a reasonable alternative for the palliative treatment of patients with locally advanced and metastatic transitional cell carcinoma. Sustained long-term survival was only found for patients with locally advanced cancer, lymphatic metastases, or solitary distant metastasis but not for visceral metastatic disease.

[Secondary malignancies in urinary diversions]. / Sekundärmalignome in Harnableitungen.

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

[Quality of life after radical cystectomy - an overview and analysis of a contemporary series]. / Lebensqualität nach radikaler Zystektomie - Ubersicht und Analyse einer aktuellen Serie.

OBJECTIVE: Published evidence does not support a clear advantage in quality of life for continent versus incontinent urinary diversion or vice versa. PATIENTS AND METHODS: We retrospectively assessed 61 patients after radical cystectomy with the EORTC-QLQ-C30 and -BLM30 instruments. Analysis was performed in dependence of age, sex, technique of urinary diversion and time-course of therapy. RESULTS: 36 patients had an incontinent and 20 patients a continent urinary diversion. Younger patients (p = 0.001) and those with a continent urinary diversion (p = 0.03) were found to have a statistically significant higher incidence of financial problems. Also patients with continent urinary diversion had significantly (p = 0.032) more problems in social integration. Furthermore, there were significant differences in social integration (p = 0.03) and emotional ability (p = 0.008) in the age-dependent analysis. Patients with a continent diversion had significantly more meteoristic problems (p = 0.007). CONCLUSION: This study also could not demonstrate any clear differences in dependence on the technique of urinary diversion. A good postoperative quality of life seems possible independent of age.

[Extracorporeal shockwave lithotripsy. Current status in treatment of kidney calculus disease]. / Extrakorporale Stosswellenlithotripsie. Aktueller Stellenwert in der Therapie des Nierensteinleidens.

The introduction of extracorporal shock wave lithotripsy has led to a revolution in stone management. After five years of clinical experience with increasing use of second generation lithotripters, the following conclusions can be drawn: There is an increasing tendency to employ ESWL for ureteral calculi, although only 60% of those can be located by ultrasound. In the case of staghorn stones, a differentiated approach is adopted (ESWL-, PCNL-monotherapy or a combination of the two) depending on stone size, localisation, chemical composition, radiodensity, and the state of the collecting system. With almost all second generation lithotripters, ESWL can be performed under i.v.-analgesia. Some machines with a large-aperture shock wave source (i.e. Wolf Piezolith, Edap LT 01, Dornier MPL 9000) even permit painfree treatment without the need for analgesia. However, this is associated with a 30% increase in retreatment rate. Further development of low-cost lithotripters and increasing use of ESWL for biliary stones make it necessary for ever more hospitals to face the question of installing such a machine. In this situation, the choice must be based on the local situation (i.e. number of patients, interdisciplinary use of ESWL).

Prone flexible cystoscopy: an adjunct to percutaneous stone removal.

Percutaneous removal of renal calculi is completed most often in the United States after initial placement of a retrograde ureteral catheter. Catheterization usually is accomplished with a rigid cystoscope with the patient in a dorsal lithotomy position, following which the patient must be turned to a prone position for percutaneous puncture and stone removal. We report our experience with the use of a flexible cystoscope with the patient in a prone position for placement of a retrograde catheter. In male patients this approach was difficult secondary to urethral length and angulation. Currently, in male patients we prefer a supine approach with the flexible cystoscope. In female patients the prone approach was performed easily. Among female patients prone cystoscopy for retrograde ureteral catheterization resulted in decreased operating room time, less manipulation of the anesthetized patient and creation of a 2-tiered field to maintain the sterility of the retrograde ureteral catheter. We found the prone approach to be feasible and effective in female patients.

Urologic experience with the Dornier multipurpose lithotripter MPL 9000.

From March, 1988 until October, 1989, 502 patients with 603 stones were treated with the Dornier multipurpose lithotripter MPL 9000. Sixty-six percent of the stones were situated in the calix, 29.6% in the renal pelvis, 3% in the upper, and 1% in the distal ureter; 18.4% of the stones were radiolucent. Multiple MPL treatments were performed in 8.6%. In 6.1% fragments post-ESWL treatment were larger than 5 mm. In 58.6% of the treatments were performed without using analgesia or anesthesia. Intravenous anesthesia was used in 22.3%, analgesia and sedation in 16.9%, general anesthesia in 1.4%, and epidural anesthesia in 0.8%. After 3 months follow-up 73.1% were stone-free. Residual fragments were found in the upper calix in 1.1%, in the middle calix in 5.2%, in the lower calix in 13.4%, in the renal pelvis in 5.9%, and in the ureter in 1%. The MPL 9000 has been proven to be as effective for the treatment of renal stones, while difficulties in localizing ureteral stones were noted. The major number of treatments were performed without any analgesia or anesthesia. No major complications were encountered.

Tissue polypeptide antigen for monitoring of advanced bladder cancer after MVEC chemotherapy.

58 patients with advanced bladder cancer were treated with MVEC chemotherapy (methotrexate, vinblastine, epirubicin and cisplatinum). 22 patients suffered from locally advanced disease (pT3-4 M0 N0), in 20 patients regional lymph node metastases were found (pT3-4 N1-3 M0). In 16 patients distant metastases were noted (pT1-4 N0-1 M1). In 89% transitional cell and in 11% squamous cell cancer or anaplastic carcinoma was seen. Complete response was noted in 45%, partial response in 23% and no response in 32%. Tissue polypeptide antigen (TPA) was registered before each course of chemotherapy and 3 months after the last application. The sensitivity for (pT3-4 N0 M0) tumors was 90.9%, for (pT3-4 N1-3 M0) 100% and for tumors with distant metastases 100% also, overall 96.6%. No statistically significant different values between each tumor group were found. In 85.7% a concordant reaction of TPA values and clinical status was notable. In conclusion, TPA has been proven as a valuable and a reliable marker for monitoring therapeutic efficacy of chemotherapy for advanced bladder cancer.

Wolf Piezolith 2200 versus the modified Dornier HM3. Efficacy and range of indications.

From February to September 1987, a prospective study was performed at two clinics to compare the Piezolith and the Dornier HM3+ lithotripters. Based on the same clinical indications for extracorporeal shock wave lithotripsy, 334 patients were treated with the Dornier HM3+ and 378 patients with the Piezolith. Whereas stone size was similar in both groups, more ureteral calculi were treated with the Dornier HM3+ (31.1 versus 23%). The rate of successful disintegration and total number of auxiliary measures were similar in both groups. However, the mean number of impulses (HM3+ 1,997 versus Piezolith 2,855) and number of secondary ESWL treatments (HM3+ 15.5% versus Piezolith 45%) differed significantly. According to the locating systems, the success of in situ treatment was similar for renal calculi; however, fewer ureteric stones could be treated in situ at the Piezolith (HM3+ upper ureter 70.6%, middle ureter 82%, distal ureter 71.4% versus Piezolith upper ureter 37.5%, middle ureter 0%, distal ureter 62.8%). The stone-free rate at discharge and after 3 months did not differ in both centers (HM3+ 75% versus Piezolith 72%).

Technical considerations using a pulsed neodym-YAG laser for endoscopic shock wave lithotripsy.

First clinical experience with the use of a Q-switched pulsed Neodym-YAG Laser showed promising results. This paper focuses on two problems with respect to the optimal use of this laser: (1) is there any need for a special iron (Fe3+)-enriched irrigant, and (2) what is the best frequency for laser lithotripsy? To answer these questions, we used an in vitro model, measuring the laser-induced breakdown (LIB) photographically utilizing sodium chloride as an irrigant enriched with different amounts of Fe3+ ions. The disintegrative efficacy of the laser was tested utilizing a standard stone model (plaster cube) and working at different frequencies (1, 10, 40 Hz). The addition of Fe3+ ions resulted in significant improvement of LIB. However, in the presence of a test stone no difference between sodium chloride and Fe3+-enriched irrigants was noted. The use of lower frequencies (1, 10 Hz) lead to a remarkable improvement in the disintegrative efficacy of the laser compared to the standard frequencies (40, 50 Hz). For clinical use, addition of Fe3+ ions seems only necessary if optical breakdown (LIB) is insufficient despite the increase in generator voltage. In such a situation, we recommend the addition of an 1-ml Fe3+ solution to 10 liters of sodium chloride irrigant (= 0.5 mg Fe3+/dl). Moreover, the standard frequency for laser-induced intracorporeal lithotripsy should be 1-10 Hz.