Management of Germ Cell Tumours of the Testes in Adult Patients: German Clinical Practice Guideline, PART II - Recommendations for the Treatment of Advanced, Recurrent, and Refractory Disease and Extragonadal and Sex Cord/Stromal Tumours and for the Management of Follow-Up, Toxicity, Quality of Life, Palliative Care, and Supportive Therapy.

OBJECTIVES: We developed the first German evidence- and consensus-based clinical guideline on diagnosis, treatment, and follow-up of germ cell tumours (GCT) of the testes in adult patients. We present the guideline content in 2 separate publications. The present second part summarizes therecommendations for the treatment of advanced disease stages and for the management of follow-up and late effects. MATERIALS AND METHODS: An interdisciplinary panel of 42 experts including 1 patient representative developed the guideline content. Clinical recommendations and statements were based on scientific evidence and expert consensus. For this purpose, evidence tables for several review questions, which were based on systematic literature searches (last search in March 2018), were provided. Thirty-one experts, who were entitled to vote, rated the final clinical recommendations and statements. RESULTS: Here we present the treatment recommendations separately for patients with metastatic seminoma and non-seminomatous GCT (stages IIA/B and IIC/III), for restaging and treatment of residual masses, and for relapsed and refractory disease stages. The recommendations also cover extragonadal and sex cord/stromal tumours, the management of follow-up and toxicity, quality-of-life aspects, palliative care, and supportive therapy. CONCLUSION: Physicians and other medical service providers who are involved in the diagnostics, treatment, and follow-up of GCT (all stages, outpatient and inpatient care as well as rehabilitation) are the users of the present guideline. The guideline also comprises quality indicators for measuring the implementation of the guideline recommendations in routine clinical care; these data will be presented in a future publication.

[Corpus cavernosum rehabilitation after radical urooncological procedures]. / Rehabilitation der Schwellkörperfunktion nach radikalen uroonkologischen Eingriffen.

Corpus cavernosum rehabilitation is an integral part of modern, quality-of-life-oriented urooncological concepts and therefore a basic task of specific urological rehabilitation. Sexual rehabilitation is based on three different therapeutic options: PDE-5 inhibitors, use of corpus cavernosum injection therapy, and use of a therapeutic vacuum device. The indication depends on the status of nerve protection. Close recovery of erectile function is possible.

[Social medical/public health assessment of the ability to work regarding urological and urooncological diseases]. / Sozialmedizinische Begutachtung der Arbeits- und Erwerbsfähigkeit bei urologischen/uroonkologischen Erkrankungen.

The primary objectives of modern urooncological treatment concepts are quality of life, reintegration and participation. Urological rehabilitation supports the overcoming of side effects of disease and treatment, which is necessary for the timely return to work life. Social medical assessment reflects the individual overall results of the entire treatment process concerning oncological prognosis, physical and mental capacity and resilience.

[Sacral nerve root cysts--a rare cause of bladder dysfunction. Case report and review of the literature]. / Sakrale Nervenwurzelzysten--Seltene Ursache von Blasenfunktionsstörungen. Fallbericht und Literaturübersicht.

INTRODUCTION: Asymptomatic cysts of the sacral nerve roots display a prevalence of 5 % and are occasionally demonstrated by MRI of the spine. Depending on their size and localization, arachnoid cysts may cause sacral or perineal pain, radicular sensomotory symptoms and neurogenic bladder and bowel dysfunction by compression of the nerve roots. CASE REPORT: We report on a case of a recently developed neurogenic bladder dysfunction. MRI of the spine demonstrated two large, liquor-filled cysts of 2.5 and 3 cm diameter, bilaterally localized at the nerve roots S2/3. Neurological and urological examinations confirmed the diagnosis of symptomatic nerve root cysts at the level S2/3, resulting in detrusor areflexia. A microsurgical excision of the cysts ameliorated the patient's pain symptoms. However, the detrusor areflexia did not improve. CONCLUSIONS: Tarlov cysts are predominantly regarded an asymptomatic incidental feature of CT and MRI scans of the spine. The case of our patient, as well as the so far published reports indicate, however, that a Tarlov cyst may cause a variety of neurological and urological symptoms. Nerve root cysts should be seriously considered and not excluded at an early stage, especially when coincident with persistent neurological and urological symptoms.

[Social medicine assessment of patients with prostate cancer]. / Sozialmedizinische Begutachtung bei Patienten mit Prostatakarzinom.

Due to the increasing incidence of prostate cancer in social-medicine-relevant age groups, a correct subject-specific evaluation of the professional capacity of these patients with all stages of disease is required. A concluding assessment is only significant when based on concrete functional deficits.

[Social medicine assessment after surgical and targeted treatment of renal cell cancer]. / Sozialmedizinische Begutachtung nach operativer und zielgerichteter Therapie des Nierenzellkarzinoms.

In Germany, renal cell cancer counts for 2.5 % of all carcinomas in women and 3.5 % in men. Curative therapy ensures good chances of recovery. But there might be permanent complications like renal insufficiency, pain, incisional hernia, flank muscle relaxation, and paresis. In addition, targeted therapy is associated with several potential side effects. In both therapy groups, severe psychological problems may occur. Still employed patients with these problems must be examined by an expert to estimate the possibilities of returning to working (positive scope of work) and occupations which can not be performed anymore (negative scope of work).

[Social medical/public health assessment of bladder cancer after curative and adjuvant therapy]. / Sozialmedizinische Begutachtung nach kurativer und adjuvanter Therapie des Harnblasenkarzinoms.

Radical cystectomy and urinary diversion are a challenge for patients. Requirements for the successful participation of the patient are sufficient urinary diversion management and recuperation/recovery as the result of urological rehabilitation. A social medical assessment reviews the individual oncological prognosis and the rehabilitation results to determine the return to work.

[Specialist uro-oncological rehabilitation after treatment for prostate cancer--update 2015. Position statement of the working group on "rehabilitation of urological and nephrological diseases" of the German Society of Urology with respect to current S3 guidelines]. / Fachspezifische uroonkologische Rehabilitation nach Therapie des Prostatakarzinoms--Update 2015. Positionsbestimmung des Arbeitskreises "Rehabilitation urologischer und nephrologischer Erkrankungen" der DGU vor dem Hintergrund der aktuellen S3-Leitlinie.

After uro-oncological primary therapy of prostate cancer the quality of life of patients is often limited. The adequate and prompt treatment of specific urological functional, physical and mental deficits has a decisive influence on the quality of life. These deficits can be recorded using instruments for measuring the quality of life, in particular the QLQ-C30 of the European Organization for Research and Treatment of Cancer (EORTC) and the SF-36 questionnaires. The quality of life is the most important parameter for quality assurance of the results. The primary objectives are the therapy of postoperative functional disorders, in particular urinary incontinence and erectile dysfunction in addition to overcoming the disease. The "urological triad" plays a central role in recovering the quality of life and patient satisfaction.

Effects of estrogen and progesterone on urinary bladder in female rabbit: evaluation by quantitative morphometric analysis.

OBJECTIVES: To investigate possible effects of estrogen and/or progesterone on the histologic characteristics of female rabbit urinary bladders, we carried out quantitative morphometric analysis of the rabbit bladders. METHODS: Mature female rabbits were treated by ovariectomy with and without successive estrogen and/or progesterone administration. Area densities of the connective tissue (CT) and smooth muscle (SM) cells, the area of single SM cells, and the thickness of the bladder wall were determined by computer-assisted quantitative morphometric analysis. RESULTS: Six weeks after each treatment, ovariectomy alone resulted in a decrease in CT density of the bladder. Successive estrogen treatment increased the bladder wet weight and SM cell density within the bladder wall. Progesterone treatment reduced CT degradation in ovariectomized rabbits. Sex steroids did not significantly influence the area of each SM cell. There was no significant difference in histologic characteristics between the rabbits treated by estrogen alone and those treated by combination (estrogen and progesterone) therapy. CONCLUSIONS: Ovariectomy and successive hormonal replacement therapy resulted in morphologic changes within the rabbit urinary bladder. Cotreatment with progesterone did not significantly change the morphologic findings produced by estrogen treatment alone.

Fetal fibronectin: a new screening-marker for bladder cancer?

Early detection of transitional cell carcinoma (TCC) of the urinary bladder is essential for effective treatment. While several serum markers have been evaluated, none have been widely accepted for practical clinical use. Thus, urinary markers have been introduced and investigated to detect the evidence of bladder cancer. But sensitivity and specificity range around 80% respectively. In a prospective study we evaluated fetal fibronectin in the urine of patients with TCC of the urinary bladder. The positivity of oncofetal fibronectin was measured in morning urine samples by membrane immunoassay. This FFN membrane immunoassay is a qualitative test, a solid-phase immunogold assay. A positive sample will result in a single spot after binding of the oncofetal fibronectin-immunogold complex to the membrane containing a monoclonal antibody specific to oncofetal fibronectin (FDC-6, which specifically recognizes III-CS region). The morning urine samples were collected from patients with TCC before they underwent transurethral resection (n=40, 34 non-invasive and 6 invasive carcinomas) and healthy controls (n=20). Oncofetal fibronectin was investigated in the surgical samples by immunohistochemistry (antibody FDC-6, APAAP technique). We found a positive result for oncofetal fibronectin in 38/40 patients with transitional cell carcinoma of the urinary bladder. Two patients with a small pTaG1-TCC showed negative results. In the urine of healthy controls no positive results were detected. Thus, there is a sensitivity of 95% and a specificity of 100%. The TCC was demonstrated as a source of oncfn. To our knowledge this is the first study showing that patients with an evident TCC have a demonstrable amount of oncofetal fibronectin in the urine. We conclude that a positive result is common in TCC-patients. The sensitivity and specificity of this test seems to be extraordinarily high. Because of the small number of cases further studies are required.

A bridge between neuroscience and oncology: prostate cancer genesis. A 'negative' consequence of learning?

Prostate cancer has become the most commonly diagnosed cancer in men over recent years. The initiating mechanism for tumorigenesis within the prostate remains an unknown. The observation, that the cancer incidence in patients with chronic neurological disabilities is significantly lower than in the normal population lead to the hypothesis, that changed processing due to a barrage of aberrant sensory information within a healthy CNS can trigger events within the prostate cell, that cause malignant transformation. There is a broad overlap of cellular mechanism of gene expression, that lead to either long term potentiation, learning and memory storage or deregulated differentiation and malignant transformation.

Ceramic coagulation tip for interstitial thermoablation of the prostate: first experiments.

A direct electrically heated ceramic coagulation tip for interstitial thermoablation has been developed. Both the coagulation tip and a laser system (Medilas 4060) were tested in vitro to compare their efficacies. We have obtained coagulation necroses of similar sizes. The electrical coagulation tip as opposed to laser coagulation is a new therapeutic option for the therapy of high risk patients with symptomatic benign prostatic hyperplasia. Because of the materials used and the principle of heating involved, certain economic and safety advantages over the laser system are offered.

[Surgical techniques in renal transplantation]. / Chirurgisch-technische Aspekte der Nierentransplantation.

Surgical techniques in renal transplantation are standardized and have remained basically unchanged for the last 50 years. A limited pool of donor organs is still an unsolved problem. Therefore, marginal organs are also used. Sophisticated techniques are used in children and in cases with vascular problems or complications. Laparoscopic techniques are emerging in renal transplantation. The article provides an overview on current technical standards of renal transplantation and potential surgical and urological complications. We report the results of our own renal transplantation program with special emphasis on vascular techniques, pediatric transplantation, and the management of complications. Special case reports are included.

[The body concept for prostate carcinoma patients. Development and testing of a questionnaire which ascertains uro-oncological patients' attitudes to their own bodies under the influence of surgery-conditioned consequences]. / Das Körperkonzept von Prostatakarzinompatienten. Entwicklung und Testung eines Fragebogens für die Erfassung von Einstellungen uro-onkologischer Patienten zum eigenen Körper unter den Einfl üssen operationsinduzierter Folgen.

BACKGROUND: The aim of this study is the construction of a questionnaire which determines uro-oncological patients' attitudes to their own bodies. The questionnaire will be tested by means of psychometric criteria for suitability. In this way, the emotional-affective and perceptual--cognitive characteristics of the body concept will be detected more effectively. PARTICIPANTS AND METHODS: For the construction, 12 interviews with patients were conducted and items from four body concept questionnaires were analysed. Subsequently, a draft version, containing 133 items, was written. A total of 305 participants (PCa n=205; healthy n=100) were questioned in 2 studies. Thereafter the suitability of the items could be checked by psychometric and factor analytical criteria. RESULTS: The psychometric testing of the statements led to a selection of the items. 40 items could be established as applicable and were therefore accepted for the final questionnaire. CONCLUSION: The indentified scales show good psychometric characteristics and also differentiate between the healthy and the clinical samples. Preliminary analyses prove the validity of the scales, although this should be subjected to further testing for assurance.

[The patient after radical prostatectomy: complexity and efficiency of a urological rehabilitation program]. / Der Patient nach radikaler Prostatektomie : Leistungsumfang und Leistungsfähigkeit der stationären urologischen Rehabilitation.

Timely physical and mental convalescence and an early recovery of functional side effects belong to an efficient treatment concept for prostate cancer. Every prostate cancer patient has a right to take part in a urological rehabilitation program (Germany). The objectives are continence, potency, overcoming physical complaints, reduction of health risk factors, and psychological support. The results presented show the complexity and efficiency of a urological rehabilitation program.

Colocalization of androgen binding protein, oxytocin receptor, caveolin 1 and proliferation marker p21 in benign prostate hyperplasia.

Androgen-binding protein (ABP) and oxytocin (OT) are among the factors that control smooth muscle proliferation and tumour growth through oxytocin receptor (OTR). A close functional interaction of OTR and caveolin 1 has been shown to modulate cell growth and proliferation. We investigated samples from 10 patients (mean age 68.3) who underwent transurethral prostate resection because of benign prostate hyperplasia (BPH) by immunohistochemistry. Post-mortem prostate samples of three young men (age 18, 28, 33) were used as controls. Tissue samples were embedded in epoxy resin and cut into serial 1 microm sections for colocalization of ABP, OTR, proliferation marker p21 and caveolin 1. ABP was found in stroma of the smooth muscle cells in all studied samples. OTR staining occurred in most of these cells in BPH while controls contained only scattered cells positive for OTR. There were no apparent differences in immunostaining for p21 while immunoreactivity for caveolin 1 was observed in most cells in BPH and only in few cells in controls. Caveolin 1 was mostly colocalized with ABP and OTR in BPH samples while controls did only occasionally show this colocalization. Our observations indicate an interaction of ABP and OTR, associated with caveolin 1, which may account in part for known non-genomic actions of gonadal steroids. Androgen dependent prostate growth in BPH may be linked to these mechanisms.

Changing caveolin-1 and oxytocin receptor distribution in the ageing human prostate.

Several observations suggest that caveolin-1 has an important role in control of cell proliferation and cancerogenesis. For instance, oxytocin provokes a proliferative response in the prostate tissue when the oxytocin receptor is localized mainly in caveolin-1-enriched domains and an anti-proliferative effect when the same receptor is not localized in caveolae. Moreover, oxytocin concentrations are elevated in prostate tissue of patients with benign prostatic hyperplasia (BPH). In this study the expression pattern of the molecules caveolin-1, oxytocin receptor, androgen receptor and p21 (cell cycle arrest indicator) was investigated in the prostate tissue of BPH patients and of young controls. We found that both caveolin-1 and oxytocin receptor expression is drastically increased with age in both smooth muscle and epithelium of the prostate. We also found a significantly increased co-localization of the oxytocin receptor with caveolin-1 in both the muscle and the epithelium, especially in BPH patients. Androgen receptor and p21 staining was found throughout the prostate but did not change significantly with age or in BPH patients. We conclude that oxytocin may have a proliferative effect on the prostate tissue through the caveolae-associated receptors and thus contribute to BPH. This process seems to be androgen receptor independent.