[Innovative concepts in early cancer detection and staging of localized prostate cancer]. / Innovative Diagnostik in der Früherkennung und beim Staging des lokalisierten Prostatakarzinoms.

Prostate cancer is the most common malignancy in males. Men aged 50 years and older are recommended to undergo an annual digital rectal examination (DRE) and determination of prostate-specific antigen (PSA) in serum for early detection. Fortunately, disease-specific mortality continues to decline as a result of advances in screening, staging, and patient awareness. However, about 30% of men with a clinically organ-confined disease show evidence of extracapsular extension or seminal vesicle invasion on pathological analysis. Consequently, there is a need for more accurate diagnostic tools for planning tailored treatment. A variety of modern imaging techniques has been implemented in an attempt to obtain more precise staging, thereby allowing for more detailed counseling, and instituting optimum therapy. This review highlights developments in prostate cancer imaging that may improve staging and treatment planning for prostate cancer patients.

[Prostate biopsy: Procedure in the clinical routine]. / Prostatabiopsie : Durchführung im klinischen Alltag.

Over the last decade there has been a 25% decrease in the mortality rates for prostate cancer. The reasons for this significant decrease are most likely associated with the application of urological screening tests. The main tools for early detection are currently increased public awareness of the disease, prostate-specific antigen (PSA) tests and transrectal ultrasound (TRUS) guided topographically assignable biopsy sampling. Together with the histopathological results these features provide essential information for risk stratification, diagnostics and therapy decisions. The evolution of prostate biopsy techniques as well as the use of PSA testing has led to an increased identification of asymptomatic men, where further clarification is necessary. Significant efforts and increased clinical research focus on determining the appropriate indications for a prostate biopsy and the optimal technique to achieve better detection rates. The most widely used imaging modality for the prostate is TRUS; however, there are no clearly defined standards for the clinical approach for each individual biopsy procedure, dealing with continuous technical optimization and in particular the developments in imaging. In this review the current principles, techniques, new approaches and instrumentation of prostate biopsy imaging control are presented within the framework of the structured educational approach.

Serum half-life time determination of free and total prostate-specific antigen following radical prostatectomy--a critical assessment.

OBJECTIVES: All studies investigating the elimination kinetics of serum total (tPSA) and free (fPSA) prostate-specific antigen (PSA) were carried out in men undergoing radical prostatectomy. Radical prostatectomy itself could, however, have a major influence on the serum concentration of these tumor markers (e.g., perioperative fluid shift or blood loss). The purpose of our study was to determine the half-life time of fPSA and tPSA with special regard to the influence of the radical prostatectomy on the serum concentration of these tumor markers. METHODS: Eleven men (mean age 63.2+/-7.2 years) with organ-confined prostate cancer who underwent radical prostatectomy were investigated (final pathologic Stage pT2pN0 or lower). Serum samples were obtained preoperatively and 0.25, 0.5, 1, 2, 4, 8, 12, 16, 24, 48, 72, 120, 168, and 240 hours after removal of the prostate. fPSA and tPSA and albumin and total protein serum concentrations were determined in all samples. RESULTS: During the first 120 minutes after removal of the prostate, albumin and total protein serum concentrations continuously declined, with a half-life time of -104.5+/-28 minutes and -129.7+/-32 minutes, respectively. Serum decline of fPSA and tPSA followed a biphasic kinetic. During the initial alpha-phase, fPSA and tPSA serum concentrations decreased, with a half-life time of -69+/-10.3 minutes and -87.3+/-18.1 minutes, respectively. During the terminal beta-phase, the half-life time of fPSA and tPSA was -1152.2 minutes (0.8 days) and -3916.1 minutes (2.7 days), respectively. Between the alpha-phase half-life time of fPSA or tPSA and the half-life time of the total protein or albumin concentration decline, significant correlations were found. CONCLUSIONS: These correlations indicate that the rapid decline of fPSA and tPSA directly after removal of the prostate (alpha-phase half-life time) is caused by the radical prostatectomy itself. The half-life time of the beta-phase reflects the biologic clearance of PSA. Therefore, the half-life time determination of PSA after radical prostatectomy is of limited value if the influence of the operation itself on the serum PSA concentration is not taken into account.

Colour Doppler ultrasound in vesicovaginal fistulas.

The purpose was to evaluate the feasibility of diagnosing vesicovaginal fistulas by colour Doppler ultrasound with contrast media. Twelve consecutive patients were examined by vaginoscopy, methylene blue test, cystogram and cystoscopy. For ultrasound examination, the bladder was filled with saline. Then diluted contrast media (Levovist) was instilled. Colour Doppler ultrasound revealed a jet phenomenon through the bladder wall toward the vagina, proving the existence of the fistula. Eleven patients had vesicovaginal fistulas, one patient a vesicoureterovaginal fistula. Colour Doppler ultrasound had correct results in 11 of 12 patients (92%). In follow-up examinations of four patients during a prolonged drainage of the bladder, we could correctly demonstrate the closure of one fistula. Colour Doppler ultrasound with contrast media is a new useful diagnostic tool in the evaluation and follow-up of vesicovaginal fistulas. It is less invasive than cystoscopy and needs no radiation exposure. The examination is well tolerated by the patients.

Virtual cystoscopy based on helical CT scan datasets: perspectives and limitations.

The purpose of the study was to simulate cystoscopy based on three-dimensional helical CT scan datasets in real-time in patients with tumours of the urinary bladder. A helical CT scan with double detector technology was carried out pre-operatively in 11 patients with histologically confirmed carcinoma of the urinary bladder and one patient with chronic cystitis. A non-enhanced scan was first performed, followed by an examination in the early phase of contrast medium enhancement. Further images were acquired after adequate filling of the bladder with contrast medium, approximately 30 min after injection. These data were transferred to a separate graphic computer workstation and reconstructed. The results were then compared with the cystoscopic and histopathological findings. All tumours of the urinary bladder identified at fibreoptic cystoscopy were shown on virtual cystoscopy. The best reconstruction results were obtained from data acquired 30 min after injection of contrast medium. The ureteric orifices were not visualized at virtual cystoscopy. These data lead us to conclude that, at present, virtual cystoscopy has not reached the quality of fibreoptic examination and remains restricted to use in specific cases, for example patients with urethral strictures.

Sensitivity of computed tomography in detecting local recurrence of prostatic carcinoma following radical prostatectomy.

The aim of this study was to evaluate CT imaging in the post-operative follow-up and in the detection of recurrence after radical prostatectomy in cases of prostatic carcinoma. In over 500 patients undergoing radical prostatectomy for prostatic carcinoma, 22 cases with local recurrence were found. CT examinations of the pelvis were retrospectively evaluated in these patients. Local recurrence was detected by PSA uptake and confirmed by transrectal ultrasound (TRUS) in combination with guided biopsy. In 22 cases of confirmed local recurrence, positive results on CT were found in eight patients (36%) and negative results in nine patients (41%). In the remaining five cases (23%), no distinction could be made between scar and local recurrence. All cases definitively classified as recurrent tumour disease showed a soft tissue mass of 2 cm or more. CT sensitivity in local recurrence of prostatic carcinoma after surgery is low. Even in a very careful follow-up, the understaging would be up to 41%. In comparison, PSA, TRUS and needle biopsy are the methods of choice and are superior to CT imaging. Based on these results, there would be no reason for including pelvic CT examinations in the follow-up of prostatic carcinoma after radical prostatectomy.

[The percutaneous transarterial embolization therapy of traumatic kidney hemorrhages]. / Perkutane transarterielle Embolisationstherapie von traumatischen Nierenblutungen.

PURPOSE: To demonstrate the possibility of transarterial, superselective embolization after traumatic kidney injury and hemorrhage in patients usually treated by surgery. METHODS: In a series of 16 patients aged 21 to 86 years (mean 37 years) external trauma led to kidney damage and consecutive bleeding. After diagnostic angiography (5 F) the exact site of hemorrhage was detected and treated by superselective embolization via a coaxial catheter system (2.7 F) either by coils (n = 5) or liquid agents (ethibloc, n = 11). RESULTS: In all patients bleeding was stopped interventionally. Additional surgical treatment was not necessary in any case. In one older patient with preinterventionally known reduced kidney function, the excretion function decreased to creatinine levels of about 3.6 mg/dl after therapy and led to compensated nephric insufficiency. Other complications were not observed. CONCLUSION: Interventional embolization is a well-tolerated and effective treatment modality after traumatic kidney hemorrhage. After exclusion of other injuries obligate for surgery, percutaneous transarterial therapy may help to avoid an operation. This reduces the risk of narcosis and treatment especially in multimorbid patients.

[3D endosonography to clarify distal ureteral processes]. / 3D-Endosonographie zur Klärung distaler Harnleiterprozesse.

PURPOSE: Evaluation of 3D endoluminal sonography as a diagnostic modality in lower ureteral pathologies. MATERIALS AND METHODS: Between December 93 and December 97, 36 consecutive patients with negative findings on IVP and still suspected ureteral obstruction were referred for transrectal or transvaginal endosonography. Patients mean age was 63 years and all of them presented clinically obvious symptoms such as colic pain and miction disturbances. RESULTS: In 31 of 36 patients (86%) 3D endosonography was diagnostic although previous IVP was negative. Reasons for ureteral obstructions were ureteral calculi in 23, urological tumours in 5 and rectal carcinoma in two cases. In one patients a gynecological tumour caused the symptomatology. In the remaining 5 patients CT/MRT or invasive retrograde ureterography/ureteroscopy had to be performed for the final diagnosis. CONCLUSIONS: The use of 3D endosonography shows encouraging results in the diagnosis of distal ureteral pathologies. In case of negative findings on IVP it should therefore precede invasive diagnostic modalities or cost intensive imaging techniques.

[Complications of transrectal prostate biopsy. Determination of current status]. / Komplikationen der transrektalen Prostatabiopsie. Eine Standortbestimmung.

The procedure for prostate biopsy has undergone a dramatic change in the last 2 decades. The introduction of PSA into diagnostics for prostate carcinoma and simultaneous development of modern biopsy techniques have led to a marked increase in transrectal prostate biopsies. At the same time, serious complications have become less frequent. Grave complications after biopsy include septic complications (approximately 1%), rectal hemorrhages (approximately 0.1%), and ischurias (0.5%). Less severe complications such as occurrence of fever without septic signs account for 3.5%. One of the frequent complications that usually do not require treatment is gross hematuria, which is observed in nearly 50% of all patients. The same applies to hematospermia with a similar frequency.In the rare cases of the altogether serious complications after prostate biopsy, appropriate action is essential. All in all, prostate biopsy nowadays represents a safe diagnostic procedure with few complications and an extraordinarily high level of usefulness for everyday urological practice.

[Improvements in surgical therapy of incontinence--failed outcome!]. / Neues in der operativen Inkontinenztherapie--Das hat sich nicht bewährt!

The general advances made in minimal invasive surgery in the last 15 years has also led to the introduction of several new techniques for treating female incontinence. In the further development of bladder neck suspension according to Stamey-Pereyra, the use of miniature bone anchors received considerable support. Bladder neck suspension according to Stamey-Pereyra yields good initial results with a low complication rate but achieves permanent continence in only 40-71%. The anterior percutaneous implantation of miniature bone anchors with the attached suspension effects continence rates between 24% and 94%. Healing rates for transvaginal application of miniature bone anchors range from 52% to 100%. Reactions to foreign bodies are particularly common with synthetics but also occur with autologous materials. They are often associated with detrusor instability or sensory urge symptoms. Though these minimally invasive techniques can reduce the severity of stress incontinence, long-term healing is only achieved in about half the cases. The techniques described appear to be particularly unsuitable for treating grade III stress incontinence. The morbidity is unacceptable, especially when synthetic material is used in combination with bone anchors. Impaired vaginal wound healing often occurs in conjunction with irritative symptoms.

[PSA volume quotient: an additional parameter in diagnosis of locally confined prostate cancer]. / PSA-Volumenquotient: Ein zusätzlicher Parameter in der Diagnostik des lokal begrenzten Prostatakarzinoms.

The sensitivity and specificity of prostate-specific antigen density (PSAD), a quotient of serum PSA and prostate volume, in the detection of localized prostate cancer was analysed in a prospective study. A total of 235 patients were examined, 145 without prostate cancer and 90 patients before radical prostatectomy for localized prostate cancer. PSAD was determined by dividing the serum level of PSA by the volume of the entire prostate (estimated by transrectal ultrasound) and multiplying by 100. Using a PSAD of 15, the specificity achieved in our collective was the same as with an absolute PSA value of 4 ng/ml (88.9-90%). On the other hand, with the PSAD of 15 we also found the same sensitivity as with an ab-solute PSA of 10 ng/ml (75.2-76.5%).

[Ultrastructural studies of the ileum neobladder]. / Ultrastrukturelle Untersuchungen an der Ileumneoblase.

Four patients had cold biopsies of the ileal mucosa 15-40 months after bladder substitution with an ileal neobladder. We used electron optical systems encompassing scanning electron microscopy and transmission electron microscopy for ultrastructural evaluation of the specimen. The changes observed did not vary markedly from patient to patient. In all biopsies the number of normal intestinal mucosa cells as well as mitochondrial density and number of microvilli was significantly reduced. In contrast the density of goblet cells was similar to that found in normal ileal tissue. These findings confirm the clinical observation that, on long-term follow-up, patients with an ileal neobladder show a decrease in urinary resorption via the ileal mucosa, whereas mucus secretion tends to be constant.

[Transurethral collagen injection for treatment of urinary stress incontinence]. / Transurethrale Kollageninjektion zur Behandlung der Stressharninkontinenz.

Minimally invasive treatment of urinary incontinence has become a subject of major interest in recent years. We examined the use of transurethral collagen injection for incontinence treatment. A total of 48 patients were selected for this procedure from April 1993 to February 1997-26 male patients (19 post-RPX incontinence and 7 post-TUR incontinence) and 22 female patients (all after previous incontinence surgery) were treated by injection of collagen into the continence region. The whole group underwent an average of 1.8 sessions, and a mean collagen injection volume of 14.5 ml was delivered per session. Mean follow-up was 9.2 months. Of the female population, 68.2% were cured or greatly improved. In the male population only 47.3% of the post-RPX patients and 6/7 of the post-TUR patients benefited from the procedure. In males, treatment outcome depends on the degree of pretreatment incontinence, because all grade III incontinence patients did worse. Therefore we conclude: transurethral collagen injection is an interesting method in the treatment of urinary incontinence if proper patient selection is assured.

[Is retrograde ureteropyelography necessary before kidney pelvis-plasty in childhood?]. / Ist die retrograde Ureteropyelographie vor einer Nierenbeckenplastik im Kindesalter erforderlich?

For routine evaluation of ureteropelvic junction obstruction in children, sonography, voiding cystogram, IV pyelogram and a renal scan in combination with administration of furosemide are available. Furthermore, often preoperative antegrade or retrograde ureteropyelography is performed. However, the significance of retrograde ureteropyelography in the world literature remains controversial. Therefore, we reviewed the records of 41 children who underwent a pyeloplasty in our department. In 9 children the ureter was visualized by IV pyelogram, voiding cystogram or antegrade ureteropyelography; a retrograde examination of the ureter was performed in 21 children before pyeloplasty in the OR. In 11 children the ureter was not visualized preoperatively. Retrograde ureterography neither gave additional information in any patient nor did it change the operative technique. In the children where the ureter was not visualized preoperatively, no ureteric abnormality was found in association with ureteropelvic junction obstruction. Hence, we conclude that retrograde ureteropyelography before pyeloplasty in children is not necessary, provided that sonography does not show ureteral dilatation.

[Intra- and postoperative morbidity of radical prostatectomy]. / Intra- und postoperative Morbidität der radikalen Prostatektomie.

Operation-related morbidity was analyzed in 147 patients, who had undergone radical prostatectomy during the last 3 years. Six major complications (4.1%) had occurred requiring surgical revision. One single postoperative death (0.7%) was caused by a pulmonary embolus. In 51 patients (34.7%) minor complications were noted. Urinary incontinence was severe in 4 patients (3.9%), which was treated by an artificial sphincter in one man during the follow-up period. Twelve patients (11.8%) complained of stress incontinence, grade I-II. Postoperative determinations of serum PSA were below the detectable range in 81% of the patients, including those with a locally advanced tumor stage and adjuvant antiandrogen therapy. Based on our data, it is concluded that radical prostatectomy is today a safe and standardized operative procedure.

[Extracorporeal shockwave lithotripsy in children. Complications and long-term results]. / Extrakorporale Stosswellenlithotripsie bei Kindern. Komplikationen und Langzeitergebnisse.

ESWL of urinary stones is a well-established treatment in adult patients. The treatment of urinary stones in children has gained increasing importance in recent years. From 1987 to 1993, a series of 27 children with urolithiasis in all parts of the urinary tract were treated by ESWL. Treatment was performed with general anaesthesia or analgosedation. During the treatment no complications occurred. On average, 34 sessions of ESWL, with 2165 shockwaves and 22.3 kV energy, were performed. Minor early complications, such as fever, pain and hydronephrosis, were observed in 7 patients. The overall stone clearance rate was 92%. Stone recurrence occurred in only 1 patient. There were no late complications, such as malfunction of the kidney, skeletal deformation or hypertension after 38 months of follow up. In conclusion, ESWL is the treatment of first choice in paediatric urolithiasis.

[Remarks on the introduction of the German Diagnosis-Related Groups (DRGs) for the specialty of urology]. / Anmerkungen zur Einführung der Deutschen Diagnosis-related Groups (G-DRGs) für das Fach Urologie.

In January 2003 a new system to charge inpatient treatment was established in Germany: the G-DRGs. This system is based on the thought that equal medical service causes equal costs all over Germany. Hospitals offering a broad spectrum of diagnostics and therapies and being unable to select their patients according to economical aspects are put at disadvantage: Despite a perfect documentation the G-DRGs reflect their medical service only in an insufficient way. Tools for an optimized coding must be a coding manual created for the specific needs of urologists and an infrastructure that allows a permanent quality control for all persons involved.

[Kidney carcinoma in Bourneville-Pringle disease]. / Nierenkarzinom beim Morbus Bourneville-Pringle.

We report a case of renal cell carcinoma in a 28-year-old woman with Bourneville-Pringle's disease. A review of the literature revealed 16 cases of renal cell carcinoma associated with tuberous sclerosis. The incidence of angiomyolipoma among patients with Bourneville-Pringle's disease is cited in the literature as 40-80%, but this is based solely on two early publications, while other publications suggest a considerably higher incidence of renal cell carcinoma in Bourneville-Pringle's disease, as in other phacomatoses (Hippel-Lindau's disease). We therefore recommend screening for renal cell carcinoma in patients with Bourneville-Pringle's disease.

[Minimally invasive treatment of stress urinary incontinence by collagen administration. Comparison between endosonography controlled and transurethral submucous collagen injection]. / Minimal invasive Behandlung der Stressharninkontinenz durch Kollagenapplikation. Vergleich zwischen endosonographisch gezielter und transurethraler submuköser Kollageninjektion.

For many years, injectable substances have been in use for the treatment of incontinence. We examined different methods of injecting glutaraldehyde cross-linked bovine collagen injection for their effectiveness in treatment of genuine stress incontinence. In the first group of patients collagen injection was done under endo-ultrasound guidance. In the second group an endoscopic system was used. There was no major difference in patient selection for the two groups. Incontinence symptoms became less severe in only 5 of 15 (33%) patients in the endo-ultrasound group, who then had moderate stress incontinence. Endoscopic collagen treatment resulted in social continence in 15 of the 22 (68.2%) patients. We conclude that endoscopic collagen is superior to endo-ultrasound-guided collagen injection in the treatment of incontinence.

[Positron emission tomography in diagnosis of renal cell carcinoma]. / Die Positronenemissionstomographie zur Diagnostik des Nierenzellkarzinoms.

PET is a new method for staging malignant tumors; the metabolism is examined and not the morphology. In this study the staging of renal cell carcinoma (RCC) by PET was investigated. In 29 patients PET with fluorodeoxyglucose (FDG) was carried out preoperatively; the PET results were compared to the histology of the OR specimen. In 26 patients a RCC was found histologically, which was diagnosed correctly by PET in 20 patients; in 6 patients a false-negative PET result was obtained. An angiomyolipoma, a pericytoma and a pheochromocytoma showed a false-positive PET result. For lymph-node staging positive nodes were found in 3 patients which was correct; no false-negative result was obtained. In 25 patients the PET result was true-positive; once a false-positive finding occurred. In conclusion, PET offers the advantage that no allergy to FDG is known and a pacemaker or metal implants are not contraindications; in diagnosing RCC, according to our results there is no further advantage of FDG-PET in comparison to standard methods; for lymph-node staging the results are equivalent