Analysis of the Impact of Clinical Factors on Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction.

INTRODUCTION: Predictive factors for the treatment success of low-intensity extracorporeal shockwave therapy (Li-ESWT) for erectile dysfunction (ED) are still under debate. METHODS: Li-ESWT was performed in 50 patients suffering from ED by applying 3,000 shock waves once a week over a period of 6 weeks. Treatment success was defined as an increase in the International Index of Erectile Function 5 (IIEF-5) score by ≥5 points or an Erectile Hardness Score (EHS) of ≥3 points. IIEF-5 and EHS were measured at baseline and at 3 and 6 months of follow-up. RESULTS: Treatment success according to either the IIEF-5 score or EHS at any time of follow-up was achieved in 28 patients (56%). Twenty-five patients (50%) experienced an improvement during the first 3 months, which lasted for 6 months in 8 cases (16%). Three patients reported improved erectile function only after 6 months. When stratifying the cohort with regard to potential influencing factors, a significantly improved IIEF-5 score could be achieved in men with cardiovascular risk factors (p = 0.026) and in men with antihypertensive medication (p = 0.009). Men without cardiovascular risk factors showed no therapeutic benefit from Li-ESWT. DISCUSSION/CONCLUSION: Li-ESWT is a valid but often short-lived treatment option for ED, especially in men with cardiovascular risk factors or controlled hypertension. Future studies should assess the feasibility and safety of repeated applications of Li-ESWT.

Kidney Autotransplantation in a 78-Year-Old Man with Proximal Ureteral Urothelial Carcinoma after Living Donor Nephrectomy.

Six years after living donor nephrectomy to his daughter, the 78-year-old donor presented to the emergency room with anuria for approximately 12 h. Only arterial hypertension, mildly reduced kidney function (eGFR 54 mL/min), and benign prostatic hyperplasia were known as preexisting medical conditions. In sonography, hydronephrosis III° was visible in the right single kidney. Ureterorenoscopy revealed an occlusive tumor in the right proximal ureter, which was treated via double J stent. Biopsy showed focal invasive papillary urothelial carcinoma of G2 high grade. Preoperative staging did not show any signs of lymph node or distant metastases. For therapeutic options, nephroureterectomy with consecutive need for dialysis was discussed versus partial ureteral resection with in situ ureteral reconstruction versus nephroureterectomy with partial ureteral resection and kidney autotransplantation. Eventually, laparoscopic right nephroureterectomy was performed with back-table preparation and tumor resection, followed by ipsilateral autotransplantation. The patient developed postsurgical acute kidney failure due to ischemia/reperfusion with a maximum serum Cr of 5.66 mg/dL (eGFR 10 mL/min), which quickly resolved. The papillary invasive urothelial carcinoma was graded pT1 pTis G2 high grade R0. Regular follow-ups showed no sign for cancer recurrence in computer tomography or cystoscopy; serum Cr was at 1.87 mg/dL (eGFR 53) 12 months after surgery.

How Octogenarians with Bladder Cancer Are Treated in a Maximum-Care Hospital: The Real-Life Experience.

INTRODUCTION: With increasing life expectancy, curative treatment of octogenarians with urothelial carcinoma of the bladder (UCB) becomes more important. MATERIALS AND METHODS: The treatment modalities of 276 octogenarians with UCB who were treated at the University Hospital of Erlangen between 1982 and 2011 were assessed retrospectively. RESULTS: One hundred forty-six patients had non-muscle invasive bladder cancer (NMIBC) while 71 had muscle invasive bladder cancer (MIBC). No data was available for 59 patients. Eighty-five (58.2%) of the 146 patients with NMIBC received transurethral resection of the bladder tumor (TURBT) only, another 38 patients (26%) underwent additional intravesical therapy; and 8.9% were treated with radiochemotherapy (RCT), 4.1% with radiotherapy (RT), 1.4% with systemic chemotherapy and 1.4% with radical cystectomy (RC). Of the 71 patients suffering from MIBC, 39 (54.9%) received TURBT alone. A potentially curative therapy was performed on 31 of the 71 patients with MIBC (43.7%). Of these, 16 patients (51.6%) received RCT, 9 patients (29.0%) RT and 6 patients (19.4%) RC. In Kaplan-Meier analysis, patients with MIBC had better median overall survival with curative treatment compared to TURBT alone (28 vs. 9 months; p < 0.001, log-rank test). CONCLUSIONS: By offering a wide range of treatment options, over 43% of octogenarians with MIBC received a curative therapy at a maximum care hospital.

Results of Renal Transplantation on Alloplastic Arterial Grafts.

BACKGROUND: The aim of this retrospective study was to report results of a consecutive series of kidney transplant patients in whom the renal artery was implanted on a prosthetic vascular graft (PVG). METHODS: Between January 2011 and December 2014, 208 deceased donor renal transplantations (68 female, 140 male, mean age 52, SD 16 years) were performed. Medical charts and outpatient clinical records of patients who had undergone renal artery implantation on a PVG were reviewed. Extensive literature research added to our 4 patients further 170 published cases during 1989 and 2015 and was compared with regular transplanted patients. Data on patient characteristics, prior vascular procedures, postoperative and long-term outcome were collected. RESULTS: Patients with transplant renal artery anastomosis on a PVG were 4 years older than the control group. Function of the graft was similar in these patients compared to regular renal transplant patients. Resistance indices assessed in our clinic over the entire follow-up period showed also no significant difference between the 2 groups. Thirty-day mortality was 6% (none in our group), which occurred mostly in combination when renal transplantation and PVG replacement was performed simultaneously. CONCLUSION: Grafting of the renal artery to a PVG is feasible and yields good results, despite the technical difficulties involved.

The value of extended transurethral resection of bladder tumour (TURBT) in the treatment of bladder cancer.

UNLABELLED: Transurethral resection of bladder tumour (TURBT) is the 'gold standard' in the diagnosis and therapy of non-muscle-invasive bladder cancer. To improve the quality of this technique an additional TUR (after 4-6 weeks) or a simultaneous photodynamic diagnosis is often offered. The present study shows different variables that influence, to a greater or lesser extent, the accuracy of the TUR diagnosis and the success of the operation. This is very important for the further management of bladder cancer, be it in tumour follow-up or in preparation for more invasive therapies. OBJECTIVE: To analyse the impact of a standardised extended transurethral resection of bladder tumour (TURBT) protocol on the determination of the residual tumour status at initial TURBT session and recurrence rate in the primary resection area. Despite, the fact that there is a clear consensus on the aims of TURBT, there is little agreement on how to perform TURBT to achieve that goal. PATIENTS AND METHODS: We retrospectively evaluated 221 consecutive patients, who underwent 305 TURBT sessions for bladder cancer, including patients with recurrent tumours. All the TURBTs were extended by taking additional deep and marginal specimens, according to a standardised protocol. Clinical and histopathological data were retrieved from the patients' records. RESULTS: Across all tumour stages, residual tumour (pR1) was found in 38% of the additionally taken specimens. There was a significant association of pR1 status with tumour stage, grade, and size. Also in the group of non-muscle-invading tumours, the rate of R1 resection was rather high at 22%. There was no association with focality and the training status of the surgeon. At follow-up, of all the patients with a unifocal primary tumour there was recurrence in the same area as the primary in 5.1%. CONCLUSIONS: Extended TURBT provides detailed information about the horizontal and vertical extent of the bladder tumour. The implementation of standardised TURBT procedures, such as our protocol of an extended TURBT, is greatly needed to improve local tumour control. Whether a diagnostic re-TUR may be restricted to those cases with positive margins or ground specimens remains to be studied.

Reduced Recurrence Rates Are Associated with Photodynamic Diagnostics Compared to White Light after Extended Transurethral Resection of Bladder Tumors.

One pillar in treating non-muscle-invasive bladder cancer (NMIBC) is the complete and high-quality transurethral resection of the primary tumor (TURBT). However, even after a high-quality primary resection, the residual tumor risk is considerable, thus requiring a re-TURBT. Resections performed with the aid of a photodynamic diagnostics report improved recurrence-free survival rates and increased detection rates of carcinoma in situ (CIS). This monocentric retrospective study reports on patients treated with an extended TURBT procedure using conventional white-light cystoscopy or photodynamic diagnostics (PDD). Only patients undergoing a TURBT resection for their primary tumor were included in the statistical analysis. Recurrence-free survival and overall survival were the clinical endpoints. Mann−Whitney U tests and chi-squared tests were used for descriptive intergroup comparisons. The associations with overall survival and recurrence-free survival were determined by univariate and multivariate analyses. The test results were considered significant when p was < 0.05. In comparison to conventional white-light cystoscopy, PDD increased the detection rates of CIS (p = 0.004) and tumor multifocality (p = 0.005) and led to reduced residual tumor incidence at the primary resection site (p < 0.001). Likewise, tumor recurrence rates were reduced in the PDD cohort (p < 0.001). Patient age and the presence of residual tumor at the primary resection site were identified as independent predictors of overall survival. For recurrence-free survival, only the PDD resection method was an independent predictor (HR = 0.43; p < 0.001). In summary, we demonstrated that the utilization of PDD techniques was associated with improved detection rates of CIS and multifocal tumors and with reduced recurrence rates. The extended resection protocol allowed us to determine that PDD resections lead to a reduced residual tumor rate at the initial resection site. This residual tumor state at the resection site, determined by extended TURBT, became an independent predictor of long-term survival. On the other hand, the PDD technique was confirmed as the only independent predictor of recurrence-free survival.

Female Gender Is an Age-dependent Negative Prognostic Factor for Patients with Upper Tract Urothelial Carcinoma.

AIM: To analyze female gender as a possible age-dependent prognostic factor for overall (OS) and cancer-specific survival (CSS) in patients with upper urinary tract urothelial carcinoma (UUTUC) after radical nephroureterectomy (RNU). PATIENTS AND METHODS: A total of 167 men and 101 women with UUTUC treated with RNU with bladder cuff resection at our clinic were retrospectively analyzed. Female patients were divided into pre- and post-menopausal groups and compared against male patients of the same age. We used a cut-off age of 59 years or more as a surrogate for the post-menopausal hormonal status of women. Kaplan-Meier analyses and multivariate Cox proportional hazards regression analyses were performed to analyze gender as a possible prognostic factor of OS and CSS. RESULTS: Women aged 59 years or more had a significantly worse CSS with an average of 231 months after RNU compared to 303 months for their male counterparts (p=0.011). Univariate Cox regression analysis showed a 2.44-fold higher risk of death (p=0.013), while multivariate analyses, adjusted for tumor stage and tumor grade, showed a 2.92-fold higher risk (p=0.011) of cancer-specific death for women aged 59 years or more. CONCLUSION: Female gender is an age-dependent prognostic factor for CSS for patients with UUTUC treated with RNU.