Functional Outcome and Complications following Ileal Neobladder Reconstruction in Male Patients without Tumor Recurrence. More than 35 Years of Experience from a Single Center.

PURPOSE: There is a lack of data on true long-term functional outcome of orthotopic bladder substitution. The primary study objective was to report our 35-year clinical experience. MATERIALS AND METHODS: Since October 1985, 259 male patients from a large single center radical cystectomy series with complete followup of more than 60 months (median 121, range 60-267) without recurrence, irradiation or undiversion that might have affected the functional outcome, were included. RESULTS: Median age at radical cystectomy and at survey was 63 (range 23-81) and 75 (range 43-92) years, respectively. Overall 87% of patients voided spontaneously and residual-free. This rate decreased with increasing age at the time of surgery (less than 50 years old 94%, 70 years old or older 82%). Overall day/nighttime continence rates were 90%/82%. These rates decreased with increasing age at the time of surgery from 100%/88% to 87%/80%. The overall pad-free rate was 71%/47%. Bicarbonate use decreased from 51% (5 years) to 19% (25 years). Patients with a followup of more than 20 years had the lowest rate of residual urine and clean intermittent catheterization (0.0%) as well as use of more than 1 pad at daytime/nighttime (6.3%/12.5%) and mucus obstruction (0.0%). Serum creatinine showed only the age related increase. The surgical complication rate was 27% and correlated inversely with functional results (chi-squared 11.227, p <0.005), even when the younger age at the time of surgery (younger than 60 years) was related to higher rates of surgical complications (chi-squared 6.80, p <0.05). CONCLUSIONS: The ileal neobladder represents an excellent long-term option for urinary diversion with an acceptable complication rate.

Intensifying the saturation biopsy technique for detecting prostate cancer after previous negative biopsies: a step in the wrong direction.

OBJECTIVE: To report the results using an extensive saturation biopsy in men with negative prostate biopsies but in whom there is still a clinical suspicion for carcinoma. PATIENTS AND METHODS: Between February 1999 and October 2004 we offered 40 patients (median age 63 years) an extensive saturation biopsy if there was clinical suspicion of prostate cancer after previous negative prostate biopsies. The median (range) number of cores taken was 64 (39-139) and was adjusted to the size of the prostate. All patients received general or spinal anaesthesia. RESULTS: Of the 40 patients, 18 (45%) had carcinoma in at least one core; 16 had a radical prostatectomy, which showed pT2a, pT2b, pT2c, pT3a and pT3b adenocarcinoma of the prostate in three, four, six, two and one patients, respectively. Brachytherapy and external radiation were the therapies of choice in the other patients. Sixteen patients had marked haematuria after the biopsy procedure. CONCLUSION: There is no significant increase in the cancer detection rate in an extensive saturation-biopsy regimen compared to published series with fewer cores, but the morbidity increased.

Imaging prostate cancer with 11C-choline PET/CT.

UNLABELLED: The ability of 11C-choline and multimodality fusion imaging with integrated PET and contrast-enhanced CT (PET/CT) was investigated to delineate prostate carcinoma (PCa) within the prostate and to differentiate cancer tissue from normal prostate, benign prostate hyperplasia, and focal chronic prostatitis. METHODS: All patients with PCa gave written informed consent. Twenty-six patients with clinical stage T1, T2, or T3 and biopsy-proven PCa underwent 11C-choline PET/CT after intravenous injection of 1,112 +/- 131 MBq 11C-choline, radical retropubic prostatovesiculectomy, and standardized prostate tissue sampling. Maximal standardized uptake values (SUVs) of 11C-choline within 36 segments of the prostate were determined. PET/CT results were correlated with histopathologic results, prostate-specific antigen (PSA), Gleason score, and pT stage. RESULTS: The SUV of 11C-choline in PCa tissue was 3.5 +/- 1.3 (mean +/- SD) and significantly higher than that in prostate tissue with benign histopathologic lesions (2.0 +/- 0.6; P < 0.001 benign histopathology vs. cancer). Visual and quantitative analyses of segmental 11C-choline uptake of each patient unambiguously located PCa in 26 of 26 patients and 25 of 26 patients, respectively. A threshold SUV of 2.65 yielded an area under the receiver-operating-characteristic (ROC) curve of 0.89 +/- 0.01 for correctly locating PCa. The maximal 11C-choline SUV did not correlate significantly with PSA or Gleason score but did correlate with T stage (P = 0.01; Spearman r = 0.49). CONCLUSION: 11C-Choline PET/CT can accurately detect and locate major areas with PCa and differentiate segments with PCa from those with benign hyperplasia, chronic prostatitis, or normal prostate tissue. The maximal tumoral 11C-choline uptake is related to pT stage.

Staging bladder carcinoma by three-dimensional ultrasound rendering.

Organ-confined staging for bladder cancer has major impact on further treatment. Most imaging techniques for this purpose are insufficient. We, therefore, assessed the value and the limitations of a new diagnostic tool, the 3-D ultrasound (US) rendering, to distinguish invasive from noninvasive bladder cancers. A total of 63 patients underwent 3-D US of the bladder before transurethral resection or radical cystectomy. The US findings were compared with the pathologic stages of the transurethral resection material or the cystectomy specimens. Superficial (pTa) carcinomas were correctly staged in 66% by 3-D US. Lamina propria infiltrating (pT1) were correctly staged in 83% and the quota of correct staging of infiltrating carcinomas (>pT1) by 3-D rendering was 100%. The overall accuracy was 79%. Three-dimensional US rendering is most valuable to discriminate between superficial stages pT1. This new technique might improve staging of bladder cancer.

Classification of incidental carcinoma of the prostate using learning vector quantization and support vector machines.

The subclassification of incidental prostatic carcinoma into the categories T1a and T1b is of major prognostic and therapeutic relevance. In this paper an attempt was made to find out which properties mainly predispose to these two tumor categories, and whether it is possible to predict the category from a battery of clinical and histopathological variables using newer methods of multivariate data analysis. The incidental prostatic carcinomas of the decade 1990-99 diagnosed at our department were reexamined. Besides acquisition of routine clinical and pathological data, the tumours were scored by immunohistochemistry for proliferative activity and p53-overexpression. Tumour vascularization (angiogenesis) and epithelial texture were investigated by quantitative stereology. Learning vector quantization (LVQ) and support vector machines (SVM) were used for the purpose of prediction of tumour category from a set of 10 input variables (age, Gleason score, preoperative PSA value, immunohistochemical scores for proliferation and p53-overexpression, 3 stereological parameters of angiogenesis, 2 stereological parameters of epithelial texture). In a stepwise logistic regression analysis with the tumour categories T1a and T1b as dependent variables, only the Gleason score and the volume fraction of epithelial cells proved to be significant as independent predictor variables of the tumour category. Using LVQ and SVM with the information from all 10 input variables, more than 80 of the cases could be correctly predicted as T1a or T1b category with specificity, sensitivity, negative and positive predictive value from 74-92%. Using only the two significant input variables Gleason score and epithelial volume fraction, the accuracy of prediction was not worse. Thus, descriptive and quantitative texture parameters of tumour cells are of major importance for the extent of propagation in the prostate gland in incidental prostatic adenocarcinomas. Classical statistical tools and neuronal approaches led to consistent conclusions.

Visualization of urinary stones by 3-D ultrasound with surface rendering.

The purpose of this study was to evaluate the diagnostic value of 3-D ultrasound with surface rendering in stones located in different parts of the urinary tract. A total of 55 patients with urinary stones were examined by transabdominal 3-D ultrasound (US) with surface rendering of the stone. In calculi of the prevesical ureter, bladder and prostatic urethra, transrectal 3-D endosonography was performed as well. The radiographic shape and the chemical analysis of the stone were correlated to the sonographic findings. The localization of the stone was: renal 23, ureteral 26, vesical 5 and urethral 1. All stones could be identified by 3-D US. Surface rendering produced useful results in stones > 2 cm with a 3.5-MHz transabdominal scanning probe, and in all stones that were accessible with a 7.5-MHz transrectal scanning probe. In stones < 1 cm, endoUS with surface rendering provides more information on the structure of the stone than plain radiography, but there is no correlation between surface and chemical analysis.

High-flow priapism: a combined interventional approach with angiography and colour Doppler.

Traumatic high-flow priapism caused by a pathologic influx from lacerated arteries to the cavernous bodies is usually treated by transcatheter arterial embolisation. The purpose of this study was to evaluate a combined interventional approach with intraoperative perineal colour Doppler ultrasound (US) while performing the embolisation procedure. Our aim was to reduce radiation exposure and application of iodinised contrast media. To achieve an optimal position of the angiography catheter directly before or in the fistula, instead of several x-ray examinations with contrast media, a perineal colour Doppler US examination was performed while saline or US contrast media were injected through the catheter. The flow pattern allows the assessment of the occlusion of the fistula and the intact flow in the arteries that were not damaged. In four patients (unilateral fistula: 1, bilateral fistulas: 3) with traumatic high-flow priapism, this technique was performed combined with a conventional angiographic control of the embolisation. Seven embolisation sessions were performed. Only in one case, a dislocation of a microcoil required a second session. In all cases, the priapism disappeared immediately after the final session, leading to a restored erectile function. This combined approach may reduce the exposure to radiation and contrast media, especially in children, who often suffer from multiple fistulas and need more than one session. The procedure also prevents an occlusion of intact arteries that affects the penile perfusion and increases the risk of erectile dysfunction.

Classification of prostatic carcinoma with artificial neural networks using comparative genomic hybridization and quantitative stereological data.

Staging of prostate cancer is a mainstay of treatment decisions and prognostication. In the present study, 50 pT2N0 and 28 pT3N0 prostatic adenocarcinomas were characterized by Gleason grading, comparative genomic hybridization (CGH), and histological texture analysis based on principles of stereology and stochastic geometry. The cases were classified by learning vector quantization and support vector machines. The quality of classification was tested by cross-validation. Correct prediction of stage from primary tumor data was possible with an accuracy of 74-80% from different data sets. The accuracy of prediction was similar when the Gleason score was used as input variable, when stereological data were used, or when a combination of CGH data and stereological data was used. The results of classification by learning vector quantization were slightly better than those by support vector machines. A method is briefly sketched by which training of neural networks can be adapted to unequal sample sizes per class. Progression from pT2 to pT3 prostate cancer is correlated with complex changes of the epithelial cells in terms of volume fraction, of surface area, and of second-order stereological properties. Genetically, this progression is accompanied by a significant global increase in losses and gains of DNA, and specifically by increased numerical aberrations on chromosome arms 1q, 7p, and 8p.

Use of transrectal ultrasound-guided biopsy in the diagnosis of pelvic malignancies.

PURPOSE: To describe our experience with transrectal ultrasound (TRUS)-guided needle biopsy of pelvic malignancies. METHODS: Eleven patients with clinical suspecion of advanced malignant pelvic tumor were referred to our institution with a history of unsuccessful CT-guided biopsy, although a target lesion was demonstrated on pelvic CT or MRI. Cholin-PET and FDG-18-PET were also obtained individually in each patient. TRUS was performed using a commercially available three-dimensional scanner. Biopsies were performed with an 18G biopsy gun. In 9 of 11 patients, biopsy was successfully performed under analgesia, whereas general anesthesia was required in the other 2 patients. RESULTS: The lesions were identified with TRUS in all patients, and biopsies were taken successfully under TRUS guidance. In all patients, the harvested material was of excellent quality and was adequate for definitive pathological diagnosis. Pathological results included 6 nodal metastases from transitional cell carcinoma, 1 case of lymph node metastasis from prostate cancer, 1 paravesical recurrence of cervical cancer, 1 metastasis from cecal cancer, and 2 cases of paravesical metastasis of a gastric cancer. CONCLUSION: TRUS-guided biopsy is a useful technique for the diagnosis of pelvic malignancies. It is faster and less expensive than CT-guided biopsy, and in most cases sufficient material can be harvested for a definitive pathological diagnosis.

Chromosomal changes in incidental prostatic carcinomas detected by comparative genomic hybridization.

OBJECTIVES: The genetic changes underlying the development and progression of prostate cancer are poorly understood. To identify chromosomal regions in incidental prostatic carcinoma (T1a and T1b) was the primary aim of this study. MATERIALS AND METHODS: We used comparative genomic hybridization (CGH) to search for DNA sequence copy number changes on a series of 48 T1 prostate cancer diagnosed by transurethral resection (TURP) and by adenomectomy. Incidental prostatic carcinomas have not been studied by CGH previously. RESULTS: CGH analysis indicated that 14 cases (29.2%) of incidental prostatic carcinoma showed chromosome alterations. The most frequent alterations were chromosomal losses of 8p (10.4%), 13q (6.3%), 5q (4.2%) and 18q (4.2%), and gains of 17p (10.4%), 17q (10.4%), 9q (6.3%) and 7q (4.2%). Minimal overlapping chromosomal regions of loss, indicative for the presence of tumor suppressor genes (TSGs), were mapped to 8p22 and 13q14.1-q21.3, and minimal overlapping regions of gain, indicative for the presence of oncogenes, were found at 9q34.2-qter, 17p12 and 17q24-qter. The statistical analysis displayed a significant association between chromosomal aberration detected by CGH and high Gleason score (P < 0.005) as well as between tumor categories T1a and T1b and chromosomal imbalance (P = 0.041). CONCLUSIONS: Studies directed at incidental prostatic carcinomas allow discovery of chromosomal changes in small and highly malignant tumors. Our results suggest that loss or gain of DNA in these regions are important in prostate cancer. This is the first study, which documents the spectrum of chromosomal changes in incidental prostatic carcinomas.

Chromosomal regions in prostatic carcinomas studied by comparative genomic hybridization, hierarchical cluster analysis and self-organizing feature maps.

Comparative genomic hybridization (CGH) is an established genetic method which enables a genome-wide survey of chromosomal imbalances. For each chromosome region, one obtains the information whether there is a loss or gain of genetic material, or whether there is no change at that place. Therefore, large amounts of data quickly accumulate which must be put into a logical order. Cluster analysis can be used to assign individual cases (samples) to different clusters of cases, which are similar and where each cluster may be related to a different tumour biology. Another approach consists in a clustering of chromosomal regions by rewriting the original data matrix, where the cases are written as rows and the chromosomal regions as columns, in a transposed form. In this paper we applied hierarchical cluster analysis as well as two implementations of self-organizing feature maps as classical and neuronal tools for cluster analysis of CGH data from prostatic carcinomas to such transposed data sets. Self-organizing maps are artificial neural networks with the capability to form clusters on the basis of an unsupervised learning rule. We studied a group of 48 cases of incidental carcinomas, a tumour category which has not been evaluated by CGH before. In addition we studied a group of 50 cases of pT2N0-tumours and a group of 20 pT3N0-carcinomas. The results show in all case groups three clusters of chromosomal regions, which are (i) normal or minimally affected by losses and gains, (ii) regions with many losses and few gains and (iii) regions with many gains and few losses. Moreover, for the pT2N0- and pT3N0-groups, it could be shown that the regions 6q, 8p and 13q lay all on the same cluster (associated with losses), and that the regions 9q and 20q belonged to the same cluster (associated with gains). For the incidental cancers such clear correlations could not be demonstrated.

Surgical intervention for complications of tension-free vaginal tape procedure.

PURPOSE: The tension-free vaginal tape procedure has become a state of the art operation for female stress urinary incontinence. Cases of complications requiring surgical revision are reported to be rare. We report on 6 patients with complications necessitating surgery. MATERIALS AND METHODS: Six patients who previously underwent the tension-free vaginal tape procedure required surgical management of complications, including intravesical polypropylene mesh tape with incrustation and chronic urinary tract infection in 2, vaginal mucosal mesh erosion of the vaginal incision in 1 and permanent urinary retention in 3. RESULTS: The intravesical tapes were resected via a suprapubic approach. In the case of disturbed wound healing the periurethral part of the tape was resected transvaginally. A patient in urinary retention underwent resection of the periurethral sling, while in the other 2 the tapes were transected transvaginally. Two patients in whom incontinence recurred were successfully treated with a repeat tension-free vaginal tape procedure during followup. CONCLUSIONS: Complications of the tension-free vaginal tape procedure that require surgical intervention are rare. The surgeon must be aware that this operation may lead to an additional surgical procedure, significantly increasing morbidity.

Evaluation of disintegration in prevesical ureteral calculi by 3-dimensional endo-ultrasound with surface rendering.

PURPOSE: Lower ureteral calculi are accessible by transrectal endo-ultrasound, including 3-dimensional image processing with surface rendering. We analyzed the efficiency of this innovative technology compared with that of standard radiographic examinations with respect to the outcome of extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Marietta, Georgia). MATERIALS AND METHODS: In patients with prevesical or intramural calculi we performed excretory urography and transrectal endo-ultrasound using a Combison 530 device (Kretz Technik, Zipf, Austria) with integrated optional 3-dimensional image processing and surface rendering. A total of 102 ESWL cases (108 radiopaque stones, 145 ESWL sessions) were included in the study. One day after ESWL an evaluation was independently performed by a radiologist (plain x-ray) and a urologist (transrectal endo-ultrasound). Results were compared to the outcome determined during further followup. RESULTS: All stones were evaluable by endo-ultrasound with surface rendering, whereas in 27 cases the stone was hidden by extraureteral processes on followup radiography. Immediately after endo-ultrasound 8 calculi were passed. In 7 of the remaining 110 cases (6.4%) radiographic examination did not confirm sonographic findings. In these cases evaluation by surface rendering proved to be correct on followup. CONCLUSIONS: Endo-ultrasound with surface rendering proved to be highly effective for evaluating ESWL success in cases of prevesical ureteral stones. This technique is independent from bowel gas or other factors that impede radiological imaging. It is safe, easy to learn, well tolerated by patients and does not expose them to radiation.

Interventional treatment of traumatic priapism.

PURPOSE: To describe the effectiveness of transarterial embolization of traumatic priapism. METHODS: Six patients ranging in age from 6 to 37 years with traumatic high-flow priapism underwent superselective embolization with gelatin sponges (n=3) or minicoils (n=3). Embolization was repeated up to 3 times. RESULTS: Embolization was successful in all cases. In 2 patients, repeated embolization led to a flow reduction in the fistula, which spontaneously occluded a few days later. All patients experienced normal erections after intervention, and no side effects were observed. CONCLUSIONS: Transarterial superselective embolization is an effective and well-tolerated therapy in patients with traumatic priapism.