Influence of lymph node degeneration on metastases in prostate cancer: or why we must look for a needle in a haystack.

BACKGROUND: To evaluate the incidence of lymph node degeneration and its association with nodal metastatic pattern in prostate cancer. METHODS: A retrospective analysis of the submitted lymph node specimen of 390 prostatectomies in 2011 was performed. All lymph nodes were histologically re-evaluated and the degree of lymph node degeneration e.g. lipomatous atrophy, capsular and framework fibrosis, and calcifications as well as the lymph node size were recorded. Lymph node degeneration was compared in the anatomic regions of the pelvis as well as in lymph nodes with and without metastases of prostatic cancer. RESULTS: Eighty-one of 6026 lymph nodes demonstrated metastases. Complete histologic examination with analysis of a complete cross-section was possible in 5173 lymph nodes including all lymph nodes with metastases. The incidence of lymph node degeneration was different across the various landing sites. Lymph node metastases were primarily detected in less degenerative and therefore more functional lymph nodes. In metastatic versus non-metastatic lymph nodes low lipomatous atrophy was reported in 84.0% versus 66.7% (p = 0.004), capsular fibrosis in 14.8% versus 35.4% (p < 0.001), calcifications in 35.8% versus 46.1% (p = 0.072) and framework fibrosis in 69.8% versus 75.3% (p = 0.53). Metastases were also identified more frequently in larger than in smaller lymph nodes (63.0% vs. 47.5%; p = 0.007). CONCLUSIONS: Degenerative changes in pelvic lymph nodes are commonly detectable but occur with variable frequency in the various nodal landing sites in the pelvis. The degree of lymph node degeneration of single lymph nodes has a significant influence on whether a lymph node is infiltrated by tumor cells and may harbour metastases.

Hydrostatic pressure of the renal pelvis as a radiation-free alternative to fluoroscopic nephrostogram following percutaneous nephrolithotomy.

BACKGROUND: We evaluated the hydrostatic pressure of the renal pelvis (RPP) as a radiation-free alternative to fluoroscopic nephrostogram to assess ureteral patency after percutaneous nephrolithotomy (PCNL). METHODS: Retrospective non-inferiority study analyzing 248 PCNL-patients (86 female (35%) and 162 males (65%)) between 2007 and 2015. Postoperatively, RPP was measured using a central venous pressure manometer in cmH2O. The primary endpoint was to assess RPP depending on the patency of the ureter and the nephrostomy tube removal. Secondary, the upper limit of normal RPP of [Formula: see text] 20 cmH2O was assessed as an indicator of an unobstructed patency. RESULTS: The median procedure duration was 141 min (112-171.5) with a stone free rate of 82% (n = 202). RPP was significantly higher in patients with obstructive nephrostogram with 25.0 mmH2O (21.0-32.0) versus 20.0 mmH2O (16.0-24.0; p < 0.001). The pressure was lower in successful nephrostomy removal with 18 cmH2O (15-21) versus 23 cmH2O (20-29) in the leakage group (p < 0.001). The analysis of a cut-off of [Formula: see text] 20 cmH2O showed a sensitivity of 76.9% (95% CI [60.7%; 88.9%]) and a specificity of 61.5% (95% CI [54.6%; 68.2%]). The negative predictive value was 93.4% (95% CI: [87.9%; 97.0%]) and the positive predictive value 27.3% (95% CI [19.2%; 36.6%]). The accuracy of the model showed an AUC = 0.795 (95% CI [0.668; 0.862]). CONCLUSION: The hydrostatic RPP seems to allow a bedside evaluation of ureteral patency after PCNL.

Effectiveness and Safety of a Modified Technique of Transvesical Obturator Nerve Block to Avoid Adductor Contractions during Transurethral Resection of Bladder Tumors.

INTRODUCTION: The aim of the study was to evaluate the effectiveness of a modified transvesical obturator nerve block (ONB) in the prevention of obturator nerve reflex and consecutive bladder perforations (BPs) during transurethral resection of bladder tumors (TURBTs). MATERIALS AND METHODS: A retrospective analysis of all patients resected in 2014-2015 due to a bladder tumor of the lateral walls, including a follow-up period until December 2018, was performed. Two groups were defined: in the first group, all patients underwent TURBT with a modified transvesical ONB. The second group underwent conventional TURBT with intermittent resection. Primary endpoints were the rates of adductor contractions and BPs. RESULTS: Ninety-four out of 1,145 resected patients presented with tumors on the lateral wall of the bladder and a complete dataset including a long-term follow-up. Thirty-six patients were treated in the ONB group, and 58 patients comprised the control group. The median age in the 2 groups was 70.8 and 71.8 years in the first and second groups, respectively. Adductor spasms were reported in 8.33 versus 25.86% (p = 0.057) and perforation in 2.78 versus 17.24% (p = 0.047) in groups 1 and 2, respectively. After a median follow-up of 32.5 months, there was no significant difference in recurrence rates (52.78 vs. 51.72%, p = 0.672). In a subgroup analysis, lower perforation rates were recorded for the ONB group in patients with tumors <3 cm (0/30 vs. 8/46, p = 0.076) and in patients with unifocal tumors (0/12 vs. 5/23, p = 0.141). DISCUSSION/CONCLUSION: The simplified approach of transvesical ONB demonstrated in this study appears to be an inexpensive, safe, effective, and simple-to-use technique.

The "Guidewire-Coil"-Technique to prevent retrograde stone migration of ureteric calculi during intracorporeal lithothripsy.

BACKGROUND: Stone retropulsion represents a challenge for intracorporeal lithotripsy of ureteral calculi. The consequences are an increased duration and cost of surgery as well as decreased stone-free rates. The use of additional tools to prevent proximal stone migration entails further costs and risks for ureteral injuries. We present the simple technique of using a coil of the routinely used guidewire to prevent stone retropulsion. METHODS: We retrospectively evaluated all patients with mid-to-proximal ureteral stones in 2014, which were treated by ureteroscopic lithotripsy (Ho: YAG and/or pneumatic lithotripsy). The preoperative stone burden was routinely assessed using low dose CT scan (if available) and/or intravenous pyelogram. RESULTS: The study population consisted of 55 patients with 61 mid-to-proximal calculi. Twentyseven patients underwent semirigid ureterorenoscopy using the "Guidewire-Coil-Technique", the second group (n = 28) served as control group using the guidewire as usual. There has been a statistically significant reduction of accidental stone retropulsion (2/27 vs. 8/28, p < 0.05) as well as a decreased use of auxiliary procedures (p < 0.05) compared to the control group. No difference was observed in operative time. One ureteral injury in the control group required a prolonged ureteral stenting. CONCLUSION: The "Guidewire-Coil-Technique" is a simple and safe procedure that may help to prevent proximal calculus migration and therefore may increase stone-free rates without causing additional costs.

Ruptured Mycotic Aortic Aneurysm after Bacille Calmette-Guerin Therapy.

To report a case of a ruptured mycotic abdominal aortic aneurysm (MAA) after intravesical Bacille Calmette-Guerin (BCG) therapy because of bladder carcinoma. A 57-year-old male patient was admitted to our hospital for follow-up computed tomography 14 months after transurethral resection of a papillary carcinoma of the bladder and intravesical BCG therapy. The CT scan revealed a ruptured MAA aneurysm and the patient underwent an endovascular repair with an aorto-bi-iliac stent graft. A ruptured MAA is a rare but lethal complication after BCG instillation therapy. The standard therapy is the open reconstruction but according to the literature an endovascular therapy in combination with long-term antibiotics should be considered as a bridging or a definite solution.

App-based Therapy of Erectile Dysfunction Using a Digital Health Application (EDDIG Study): A Randomized, Single-blind, Controlled Trial.

BACKGROUND AND OBJECTIVE: While international guidelines advocate for a multifaceted approach to treating erectile dysfunction (ED) involving physical activities, psychological support, and education, structured programs are infrequent. To address this gap, an app-based therapy was developed, offering a systematic approach. This randomized, single-blind controlled trial aimed to assess the effectiveness of an app-based therapeutic in improving ED. METHODS: A total of 241 patients (49.74, standard deviation 12.73 yr) with ED (International Index of Erectile Function [IIEF]-5 <22) were randomized to the 12-wk app-based therapy (treatment group [TG], n = 122) or a waiting list for the app with continuation of their current management protocol (control group [CG], n = 119). Patients on long-term medication for ED were included, but subsequent exclusion occurred for those starting new medication. Coprimary endpoints were improvements from baseline to 12 wk in erectile function (IIEF-5), disease-related quality of life (QOL-Med-15), and patient activation (Patient Activation Measure [PAM-13]). KEY FINDINGS AND LIMITATIONS: Erectile function (IIEF-5) improved by 4.5 points in the TG versus 0.2 points in the CG (p < 0.0001, 95% confidence interval [CI] 3.4-5.0) group. Quality of life (QOL-Med) improved by 20.5 points in the TG versus -0.0 points in the CG (p < 0.0001, 95% CI 19.2-26.0) group. Patient activation (PAM-13) improved by 11.2 points in the TG versus 0.6 points in the CG (p < 0.0001, 95% CI 9.1-13.6) group. Phosphodiesterase type 5 inhibitor intake had no influence on all observed treatment effects. CONCLUSIONS AND CLINICAL IMPLICATIONS: App-based therapy of patients with ED provided a significant, clinically meaningful improvement. Quality of life and patient activation were also enhanced significantly. This program has the potential to change clinical practice in the treatment of ED. PATIENT SUMMARY: A therapy app improved sexual function and overall well-being for men experiencing erectile dysfunction, leading to better quality of life.

[Robotic-assisted resection of a symptomatic Müllerian duct cyst]. / Roboter-assistierte Resektion einer symptomatischen Müller-Gang-Zyste.

Cysts in the lesser pelvis are a rare disease and most often an incidental finding from routine diagnostic investigation. Published information is controversial. These cysts are distinguished by localisation, content of the cyst and accompanying anatomical anomalies. In this case, we report a 33 years old man who presented to our clinic due to a large retrovesical cyst. Because of lower abdominal pain and problems with defecation, the cyst was diagnosed by ultrasound. Further radiological diagnostic testing confirmed the presence of a retrovesical cyst of unknown malignancy, which was retrospectively evaluated as a Müllerian duct cyst. Due to symptoms and potential malignancy of the cyst, the decision was made to perform surgery. With the help of the operation robot, this benign cyst was safely and completely removed. In a follow-up, the patient presented free of symptoms and sonographically there was no sign of recurrence. Therefore robotic-assisted resection is a safe procedure to treat large symptomatic Müllerian duct cysts.

Correction: Luedemann et al. Prostate Cancer-Associated miRNAs in Saliva: First Steps to an Easily Accessible and Reliable Screening Tool. Biomolecules 2022, 12, 1366.

The authors wish to make the following corrections to their paper [...].

Prostate Cancer-Associated miRNAs in Saliva: First Steps to an Easily Accessible and Reliable Screening Tool.

BACKGROUND: Common diagnostic tools for prostate cancer-prostate-specific antigen and transrectal biopsy-show only low predictive value and poor sensitivity. This study examines circulating miRNA in saliva to explore the possibility of a non-invasive and easy-to-execute diagnostic tool for prostate cancer screenings. METHODS: 16 miRNAs were extracted from salivary exosomes and analyzed via the delta-CT method. The presented method enables an application of the test in any health institution and even outpatient sector. Recruited participants were suspected to suffer from prostate cancer due to elevated PSA serum levels. Of these participants, 43 were diagnosed with prostate cancer, while 31 suffered from benign diseases and served as control group. RESULTS: hsa-mir-331-3p and hsa-mir-200b were significantly reduced in prostate cancer patients compared to the control group. ROC curve analysis revealed a reliable differentiation strength (AUC &gt; 0.6) for both miRNAs with positive predictive values of 71% indicating prostate cancer. Differentiation of both groups based on PSA serum measurements was insufficient. The other 14 examined miRNAs showed no significant group differences. CONCLUSIONS: The presented method and miRNA are promising non-invasive tools to augment the current prostate cancer screening, thereby improving screening sensitivity and reducing numbers of false positive cancer suspects admitted to further invasive diagnostic and therapeutic steps.

The natural history of muscle-invasive bladder cancer in geriatric patients undergoing transurethral resection only: Outcome and cost.

PURPOSE: Bladder cancer is predominant in the elderly. Up to 70% of geriatric patients with muscle-invasive bladder cancer do not receive curative treatment. We analyzed the outcome of patients managed only by transurethral resection of bladder tumor (TURBT) without chemo- or radio-therapy, and performed a cost analysis of the cumulative inpatient interventions throughout the course of the disease. METHODS: From 2010 to 2016 81 patients ≥75 years with de novo muscle-invasive bladder cancer who were not eligible for curative treatment options were analyzed retrospectively. All patients were treated only with TURBT. Overall survival (OS) was measured by Kaplan-Meier plots (log-rank test) and clinical parameters predicting OS by a multivariate analysis. The cost analysis was based on actual billing from the hospital provider and referenced standardized pricing in Germany for bladder cancer treatment. RESULTS: The median age was 83 years. The OS was 11 months, the 1-year OS was 42%. In the multivariate model Charlson Comorbidity Index <8 (P = 0.016), tumor size ≤3 cm (P = 0.011), complete (T0) tumor resection (P = 0.003), normal C-reactive protein level (P = 0.010), and initial elective surgery (P = 0.035) were shown to be independent predictors of longer OS in palliative TURBT regimes. Median treatment cost for the TURBT regimen was $16,175 vs. $16,467 for a salvage radical cystectomy in this cohort. CONCLUSIONS: In a TURBT-only concept elective surgery, tumor size, Charlson Comorbidity Index, C-reactive protein level and complete TURBT are independent predictors of OS. The treatment-related cumulative cost appears to be higher in patients not managed by cystectomy.

Impact of CYP2D6 Polymorphisms on Tamoxifen Treatment in Patients With Retroperitoneal Fibrosis: A First Step Towards Tailored Therapy?

OBJECTIVE: To investigate the influence of CYP2D6 polymorphisms on outcomes and health-related quality of life of patients with retroperitoneal fibrosis (RPF) receiving tamoxifen (TMX). TMX is an effective alternative to corticosteroids for patients with RPF. Conversion of TMX to more potent endoxifen is dependent on enzyme activity of CYP2D6. MATERIALS AND METHODS: CYP2D6 genotyping and phenotype prediction of all patients treated with TMX between 02/2007 and 01/2018 was assessed using multiplex polymerase chain reaction (PCR). Groups were classified by phenotype: extensive (EM) vs poor and intermediate (PM + IM) vs ultrarapid metabolizer (UM). Retrospective evaluation of outcome (including magnetic resonance imaging and positron emission tomography-computed tomography) and health-related quality of life using the SF-36 was performed. RESULTS: A total of 63/194 patients received TMX, 40/63 with complete follow-up were sequenced: Twenty-nine patients with EM phenotype, 8 PM + IM and 3 UM. The median therapy duration was 364.5 days with a mean follow-up of 62.9 months. Seven therapy terminations occurred due to lack of response (17.5%), including all UM patients (P <.001). Magnetic resonance imagings showed a regression of fibrosis for EM and PM + IM in 69% and 62.5% of cases and a progression for UM in 100% (P = .004). In positron emission tomography-computed tomography, glucose utilization of RPF decreased significantly for EM and PM + IM. The physical sum-score of SF-36 improved for EM and PM + IM and decreased for UM (P <.05). The removal of DJ-stents was successful for EM, PM + IM, and UM in 48.3%, 75%, and 0% of cases (P = .0581). CONCLUSION: Contrary to expectations, UM showed the lowest success rate, which concludes that genotyping of RPF-patients may be useful in the sense of a tailored-therapy.

Technique of Suprafascial Anastomosis With Reduced Risk of Stenosis of the Efferent Outlet in Continent Catheterizable Urinary Diversion.

OBJECTIVE: To describe our technique and long-term experience with a technique of a suprafascial anastomosis for the efferent continent segment in continent cutaneous urinary diversion, which aims to reduce the rate of stomal strictures. MATERIALS AND METHODS: Between 1998 and 2013, up to 191 patients underwent continent cutaneous urinary diversion with a suprafascial anastomosis technique at our institution. A complete follow-up was achievable in 82 patients. The retrospective analysis included continence rates, stomal complications, and other complications related to the urinary diversion such as anastomotic insufficiencies, fistulas, or hernias. RESULTS: The study population consisted of 82 patients with 67 (82%) women and 15 (18%) men with a median age of 58 years. The median length of follow-up was 82 months (range 13-203) with a median survival time of 46 (range 13-193) months. At the time of the analysis, 46 patients (57%) were still alive. Five out of 82 patients (6%) presented with a relevant stenosis in umbilical stoma that required surgical revisions. Nine patients (12%) with functional stenosis could be treated conservatively. Continence was achieved in 74 of 82 patients (90%). Only 8 patients reported some degree of incontinence. CONCLUSION: The technique of a suprafascial stoma is a simple and safe technique that may help prevent the incidence of stomal complications.

Diagnostic Accuracy of Renal Mass Biopsy: An Ex Vivo Study of 100 Nephrectomy Specimens.

We investigated the diagnostic accuracy of renal mass biopsy in an ex vivo model, as well as compared the agreement of the preoperative radiological diagnosis with the final pathologic diagnosis. Two 18-gauge needle-core and 2 vacuum-needle biopsies were performed ex vivo from the tumors of 100 consecutive patients undergoing radical nephrectomy between 2006 and 2010. The median tumor size was 5.5 cm. There was no significant difference with regard to cylinder length or tissue quality between the sampling methods. At least 1 of 4 needle cores contained diagnostic tissue in 88% of patients. Biopsy specimens identified clear cell (54%), papillary (13%), or chromophobe (5%) renal cell carcinoma; urothelial carcinoma (6%); oncocytoma (5%); liposarcoma (1%); metastatic colorectal carcinoma (1%); squamous cell carcinoma (1%); unclassified renal cell neoplasm (1%); and no tumor sampled (12%). The sensitivity of the biopsy for accurately determining the diagnosis was 88% (95% CI: 79% to 93%). The specificity was 100% (95% CI: 17% to 100%). Biopsy grade correlated strongly with final pathology (83.5% agreement). There was no difference in average tumor size in cases with the same versus higher grade on final pathology (5.87 vs 5.97; P = .87). Appraisal of tumor histology by radiology agreed with the pathologic diagnosis in 68% of cases. Provided that the biopsy samples the tumor tissue in a renal mass, pathologic analysis is of great diagnostic value in respect of grade and tumor type and correlates well with excisional pathology. This constitutes strong ground for increasingly used renal mass biopsy in patients considering active surveillance or ablation therapy.

Urosepsis--Etiology, Diagnosis, and Treatment.

BACKGROUND: Sepsis is among the most common causes of death in Germany. Urosepsis accounts for 9-31% of all cases and has a mortality of 20-40%, which is low compared with that of sepsis in general. As the population ages, the incidence of urosepsis is likely to rise. METHODS: Review of pertinent articles and guidelines retrieved by a selective search in PubMed. RESULTS: Enterobacteria and Gram-positive organisms are the pathogens that most commonly cause urosepsis. The diagnosis can and must be made early on the basis of the typical clinical features, altered vital signs, and laboratory abnormalities, so that timely treatment can be initiated. 80% of cases are due to obstructive uropathy. The diagnostic evaluation includes physical examination, blood cultures, urinalysis, procalcitonin measurement, and ultrasonography. In one study, each additional hour of delay in the treatment of urosepsis with antibiotics was found to lower the survival rate by 7.6%. Antibiotics should be chosen in consideration of local resistance patterns and the expected pathogen spectrum. CONCLUSION: Urologists, intensive care specialists, and microbiologists should all be involved in the interdisciplinary treatment of urosepsis. Patients' outcomes have improved recently, probably because of the frequent use of minimally invasive treatments to neutralize foci of infection. New biomarkers and new treatments still need to be validated in multicenter trials.