[Modern interdisciplinary management of a uretero-iliac artery fistula (case report)]. / Modernes interdisziplinäres Management einer uretero-iliakalen Fistel (Fallbericht).

INTRODUCTION: Abnormal links between the arterial system and other luminal systems are a challenge to those in charge of their adequate diagnostic and therapeutic management. OBJECTIVE: Scientific case report on an individual who underwent successful treatment combining vascular-surgical and interventional radiology techniques for a rare right uretero-iliac artery fistula based on personal clinical experience, a selective literature research and a detailed discussion of current recommendations for diagnostic workup and subsequent treatment. CASE CHARACTERISTICS: A 79-year-old patient was admitted with haematuria : and bladder tamponade : in the presence of bilateral actinic ureteral strictures secondary to neoadjuvant radiochemotherapy followed by abdominoperineal rectum exstirpation due to suprasphincteric rectal cancer (ypT3ypN0M0). Laboratory tests revealed anaemia; transabdominal ultrasound demonstrated bilateral urinary retention. A complementary CT scan did not reveal any manifest bleeding resulting from intermittent haemorrhage. SURGICAL PROCEDURE: Initially, the bladder haematoma was removed and ureteral catheters were changed. Due to endoluminal bleeding in the right ureter, a combined procedure was initiated, involving a vascular-surgical approach (access to the right femoral artery, ultimate disobliteration and intimal refixation in the right superficial femoral artery due to dissection) and an interventional radiology approach (insertion of an Amplatzer [AMPLATZER™Vascular Plug II; St. Jude Medical, Saint Paul, Minnesota, USA] into the right internal iliac artery and iliac stenting by a cross-over manoeuvre from the left femoral access site) although no acute bleeding was detected in the CT scan (but acute haemorrhage from the right ureteric ostium was confirmed during cystoscopy). CLINICAL COURSE: The patient stabilised in due time in response to periinterventional treatment in the ICU. He was discharged on the 15th day after surgery without evidence of recurrent haemorrhage. SUMMARY: In the presented case, this promptly initiated (vascular-surgical and interventional radiology) hybrid operation was absolutely indicated, being the approach with the best prospects for recurrent arterial bleeding with clinical manifestation of haematuria and haemorrhage within the urinary bladder due to a uretero-iliac artery fistula. CONCLUSION: Today, a minimally invasive approach with stenting is the method of choice in the sequential, urgent management of a potentially life-threatening uretero-iliac fistula in the presence of arterial endoluminal bleeding and an imminent haemorrhagic shock.

[High-intensity focussed ultrasound in low-risk prostate cancer - oncological outcome and postinterventional quality of life of an inexperienced therapy centre in comparison with an experienced therapy centre]. / Hochintensiver fokussierter Ultraschall bei Low-Risk Prostatakarzinom - Onkologisches Outcome und postinterventionelle Lebensqualität im direkten Vergleich eines erfahrenen und unerfahrenen Therapiezentrums.

BACKGROUND: In patients with low-risk prostate cancer (PCa) the standard therapies carry a risk of overtreatment with potentially preventable side effects whereas restrained therapeutic strategies pose a risk of underestimation of the individual cancer risk. Alternative treatment options include thermal ablation strategies such as high-intensity focused ultrasound (HIFU). PATIENTS AND METHODS: 96 patients with low-risk PCa (D'Amico) were treated at 2 HIFU centres with different expertise (n=48, experienced centre Lyon/France; n=48 inexperienced centre Charité Berlin/Germany). Matched pairs were formed and analysed with regard to biochemical disease-free survival (BDFS) as well as postoperative functional parameters (micturition, erectile function). The matched pairs were discriminated as to whether they had received HIFU treatment alone or a combination of HIFU with transurethral resection of the prostate (TURP). Patients of the Lyon group were retrospectively matched through the @-registry database whereas patients of the Berlin group were prospectively evaluated. In the latter patients quality of life assessment was additionally inquired. RESULTS: Postoperative PSA-Nadir was lower in the Berlin group for patients with HIFU only (0.007 vs. Lyon 0.34 ng/ml; p=0.037) and HIFU+TURP (0.25 vs. Lyon 0.42 ng/ml; p=0.003). BDFS was comparable in both groups for HIFU only (Berlin 4.77, Lyon 5.23 years; p=0.741) but patients with combined HIFU+TURP in the Berlin group showed an unfavourable BDFS as compared to the Lyon group (Berlin 3.02, Lyon 4.59 years; p=0.05). In an analysis of Berlin subgroups especially patients who had received HIFU and TURP (n=4) within the same narcosis had an unfavourable BDFS (p=0.009). Median follow-up was 3.36 years for HIFU only and 2.26 years for HIFU+TURP. Neither HIFU only (p=0.117) nor HIFU+TURP (p=0.131) showed an impact on postoperative micturition. Erectile function was negatively influenced (HIFU: p=0.04; HIFU+TURP: p=0.036). There was no measurable change in quality of life after the treatment. CONCLUSION: The 4-year BDFS after HIFU and HIFU+TURP is comparable to that of the standard therapies. The erectile function is sustainably negatively influenced whereas postoperative micturition and quality of life were not affected by HIFU or HIFU+TURP. These results are strongly limited by the low patient count and the short follow-up period and require validation in prospective multicentre studies with higher number of cases.

[Irreversible electroporation: the new generation of local ablation techniques for renal cell carcinoma]. / Irreversible Elektroporation : Die neue Generation lokaler Ablationsverfahren beim Nierenzellkarzinom.

BACKGROUND: Local ablation techniques are a major focus of current developments in oncology. The primary aim is to retain organs and preserve organ functions without compromising the oncological outcome. METHOD: Irreversible electroporation (IRE) is a novel ablation technique that involves the application of high-voltage pulses to induce cell apoptosis without causing thermal damage to the target tissue or adjacent structures. AIM: First published in 2005 IRE is currently undergoing preclinical and clinical trials in several areas of oncology and the initial results have been promising. The IRE technique could be a significant development in ablation treatment for renal cell carcinoma (RCC) but decisive proof of its effectiveness for local RCC has not yet been provided. This study presents the results of preclinical and initial clinical trials which are discussed and compared with those of other ablation techniques in order to demonstrate the current value of IRE.

[Magnetic resonance urography in pediatric urology]. / Magnetresonanzurographie in der Kinderurologie.

Magnetic resonance urography (MRU) provides high resolution imaging of the urogenital system and the use of paramagnetic contrast agents enables a functional depiction. This review summarizes existing data concerning this diagnostic procedure in pediatric urology. A systematic search and assessment of the literature was performed.A total of 12 studies were reviewed in detail. In mostly small study populations a great heterogeneity concerning methodology, use of comparative examinations and standards of reference was noted. Besides the quality of anatomical imaging, the functional study of renal excretory function and differential renal function was also assessed. Only a few studies performed statistical analyses.The authors' rating of MRU was mostly positive. Due to methodical weaknesses, lack of independent standards of reference and statistical analyses the overall level of evidence was low. Further high quality studies will be necessary to assess the value of MRU for the diagnostic workup in pediatric urology.

[Long-term results for subcutaneous Detour® prosthesis for ureteral obstruction: experiences of implantation, aftercare and management of complications]. / Langzeitergebnisse zur subkutanen Detour ®-Harnleiterprothese bei Ureterobstruktion : Erfahrungen zu Implantation, Nachsorge und Komplikationsmanagement.

BACKGROUND: We present the long-term results of implementation of the Detour® prosthesis as an alternative to established methods of surgical, percutaneous or internal urinary diversion. PATIENTS AND METHODS: Between 2004 and 2012 a total of 40 prostheses were implanted in 31 patients (mean age 65 years) with ureteral strictures of various origins. In the follow-up the patients underwent examinations and completed questionnaires. RESULTS: The average follow-up was 23 months (range 1-92 months). Sonographic examinations showed no urinary retention in 38 out of 40 implanted systems. The retention values were stable in 19 patients, improved in 7 and worse in 3. The quality of life (QoL) was high (EORTC QLQ-C30 90%). Intraoperative complications were 2 intestinal lesions and 3 bleeding of the renal-pelvic system. Postoperative urinary tract infections and wound complications were encountered. In the long-term course three infected hydronephroses occurred which were treated and cured with antibiotics and temporary nephrostomy and 4 systems were explanted, including 2 exchanges. CONCLUSIONS: The system may be considered for patients with ureteral strictures with palliative and curative intent. There were no significant disadvantages in comparison with established methods. There were fewer risks in implantation and complications were manageable. The quality of life was significantly improved.

[Placement of percutaneous nephrostomy by open magnetic resonance imaging: clinical results and current status in urology]. / Einlage einer perkutanen Nephrostomie im offenen Magnetresonanztomographen : Klinische Ergebnisse und aktueller Status in der Urologie.

BACKGROUND: Percutaneous nephrostomy (PCN) tube placement under combined ultrasound and fluoroscopic guidance is a standard procedure in urology. The use of a 1 Tesla open magnetic resonance imaging (MRI) scanner enables PCN placement under real-time guidance. METHOD: In the present series 51 patients underwent a total of 79 MRI-guided procedures between 2008 and 2012 and 52 interventions were performed after failure of conventional urological manipulation. Of the procedures 55 involved only a minor urine transport disorder (UTD) or none at all. RESULTS: Puncture and subsequent PCN tube placement were successful in all patients. Extravasation was found in four patients and renal pelvic clots in three. All complications healed without sequelae or further interventions. CONCLUSION: The MRI-guided PCN tube placement is an optimal alternative, particularly in cases of limited conventional imaging.

[HIFU in salvage treatment of patients with prostate cancer after primary external radiation therapy--status 2012]. / HIFU in der Salvage Behandlung von Patienten mit Prostatakarzinom-Rezidiv nach primärer externer Bestrahlungstherapie - Status 2012.

BACKGROUND: Patients with (local) recurrence of prostate cancer after radiation therapy face the question of the appropriate diagnostic and possible therapeutic options. Many patients in this setting receive palliative androgen deprivation therapy alone, with arguable impact on overall cancer survival. In the case of an isolated local recurrence, salvage prostatectomy represents a potentially curative therapeutic option, albeit with a high complication rate. Alternatively, these patients can be offered a local treatment with salvage HIFU therapy. MATERIAL AND METHODS: Salvage HIFU therapy is based on the thermal ablation of tissue through high-intensity focused ultrasound. In addition, the formation of microbubbles (cavitation) and their implosion lead to an enhancement of tissue ablation. RESULTS: The results of 6 monocentric studies (2004-2011) with an overall number of 408 patients (22-167 patients) are presented and critically reviewed. The median follow-up was 18.71 months (7.4-39). The 3-year progression free survival (PFS) varied from 25% (D'Amico high risk) to 53% (D'Amico low-risk), the 5-year overall survival was 90%. The rate of urinary incontinence varied between 7 and 60% in all grades (grade III urinary incontinence 0-9.5%). In 22 cases surgical incontinence treatment was performed. 53 patients developed a urethral stricture or stenosis leading to surgical treatment. Urethral-rectal fistulae were seen in 0-7%. CONCLUSIONS: The current data on salvage HIFU can be evaluated as insufficient. The main criticisms can be seen in the lack of randomization, the monocentric and retrospective analyses of the data, the heterogeneous stratification of risk groups as well as inadequate definition of postinterventional treatment failure. The studies indicate that salvage HIFU therapy leads to a mid-term overall survival with complication rates that are comparable to those of other local salvage therapies. Randomized multicentric studies are needed to further validate the results of salvage HIFU therapy.

[Aggressive fibromatosis (desmoid tumor) : A rare differential diagnosis of metastasis of renal cell carcinoma]. / Aggressive Fibromatose (Desmoidfibromatose) : Seltene Differentialdiagnose einer Nierenzellkarzinommetastase.

We report the case of a 65-year-old woman with an aggressive fibromatosis of the rectus abdominis muscle suspicious for a metastasis of renal cell carcinoma after tumor nephrectomy 3 years previously. Aggressive fibromatoses (desmoid tumors) are rare semimalignant tumors of the connective tissue with local infiltration and destruction of tissue. Complete resection is essential to avoid tumor relapse. Aggressive fibromatosis must be considered in the differential diagnosis of renal cell carcinoma metastasis. Complete resection and subsequent radiotherapy seem to be the therapy of choice.