[Visual diagnosis while performing transurethral resection of bladder tumors: power or myth?]. / Blickdiagnose bei der transurethralen Resektion von Harnblasentumoren : Macht oder Mythos?

INTRODUCTION: The gold standard for diagnosis and immediate therapy of bladder cancer is a transurethral resection (TURB) followed by histopathologic evaluation. The aim of this study was to assess the reliability of visual diagnosis by the operating urologist concerning dignity (malignant/benign) and staging compared to histopathologic evaluation. This is especially crucial since early mitomycin C instillation is based on the urologist's first impression. STUDY DESIGN AND METHODS: This prospective study included 311 cases of TURB from five German institutions. Surgeons were asked to estimate dignity of the neoplasm, tumor stage, and grade according to a standardized questionnaire. RESULTS: The subjective estimation/visual diagnosis of the operating urologist achieved a sensitivity with respect to identifying malignant tumors as such of 97%, while specificity was only 41%. Accordingly, the positive (PPV) and negative predictive values (NPV) were 76% and 88%, respectively. In general, muscle invasive cancer was predicted more often than confirmed by pathology (PPV 52%). However, whenever muscle invasive cancer was excluded by the urologist, this was confirmed by the pathologist in most the cases (NPV 95%). The educational degree did not influence the reliability and predictive value of visual diagnosis. CONCLUSION: This study shows that urologists cannot reliably distinguish benign from malignant lesions of bladder mucosa-regardless of their educational degree. A reliable diagnosis of a pathologist is definitely needed to plan final therapeutic steps.

[Secondary malignancies in urinary diversions]. / Sekundärmalignome in Harnableitungen.

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

[Fistula between the bladder and vagina and perforation after implantation of a wall stent for ureteral stricture]. / Harnblasenscheidenfistel und -perforation nach Implantation eines Wallstents bei Ureterstenose.

The implantation of metal stents in the ureter is an alternative therapeutic option for treating ureteral strictures of different origins. We report the case of a female patient who was treated with a ureteral wall stent because of stenosis caused by radiotherapy. Subsequently the stent migrated into the bladder and led to incrustation and stone formation. This finally led to development of a vesicovaginal fistula and bladder perforation into the os pubis.

Urodynamic outcome of waterjet-assisted total mesorectal excision.

BACKGROUND: Waterjet dissection has been proposed for total mesorectal excision. The present study investigated its impact on urodynamic function and oncological outcome. METHODS: Thirty patients with rectal cancer were recruited to this prospective study, of whom 25 underwent urodynamic evaluation both before and after surgery. RESULTS: All patients were capable of spontaneous micturition at a median of 5 months after surgery. Urodynamic measurements revealed a decrease in detrusor pressure of more than 30 mmHg, and residual urine volumes of between 100 and 200 ml, in three patients. No patient had a complete neurogenic voiding disorder. Local recurrences developed in two of 22 patients. CONCLUSION: The extent of micturition disorders observed after total mesorectal excision using the waterjet method in this small series is encouraging.

[Blunt testicular injury - conservative or surgical treatment?]. / Stumpfes Hodentrauma - wann konservative, wann operative Behandlung?

INTRODUCTION: Testicular trauma can be classified into blunt or penetrating injury. While every case of penetrating trauma is subjected to surgical treatment, the decision between surgery and conservative treatment must be made for each case of blunt injury. Inspection, palpation and duplex sonography may be helpful in finding the correct decision. Herein we present a case report and review of the current literature. CASE REPORT: A 14-year-old boy was admitted to an urological department after blunt scrotal trauma. Ultrasound examination revealed a peritesticular hematoma. After 9 days of conservative treatment, surgical exploration and orchidectomy for rupture of the tunica albuginea was performed. CONCLUSIONS: The following recommendations can be made for treatment of blunt testicular injury: if rupture of the testis is detected sonographically, immediate surgical exploration is indicated. Every change in testicular structure must be considered a possible sign of testicular rupture. Sonographically detected hematoceles without visible signs of rupture are not given clear recommendations in the literature. However, early surgical intervention (within 72 hours) seems to increase the likelihood of preserving the testis. In every case of unclear clinical or sonographic findings, surgical exploration of the scrotum should be done. If offers a safe and quick diaganosis with a very low complication rate.

[European Association of Urology guidelines on urinary and male genital tract infections]. / Synoptische Leitlinie der sexuell übertragbaren Erkrankungen (STD) mit Primärsymptomen im männlichen Genitale (S1). Leitinien der Deutschen Gesellschaft für Urologie.

Today, the classical bacteria that cause venereal diseases, e.g. gonorrhea, syphilis, chancroid and inguinal granuloma, only account for a small proportion of all known sexually transmitted diseases (STDs). Other bacteria and viruses as well as yeasts, protozoa and epizoa must also be regarded as causative organisms of STD. Taken together, all sexually transmitted infections comprise more than 30 relevant STD pathogens. However, not all pathogens that can be sexually transmitted manifest diseases in the genitals and not all infections of the genitals are exclusively sexually transmitted. Concise information and tables summarising the diagnostic and therapeutic management of STDs in the field of urology allow a synoptic overview, and are in agreement with the recent international guidelines of other specialist areas. Special considerations (i.e. HIV infection, pregnancy, infants, allergy) and recommended regimens are presented.

Expression of the MRP2 gene-encoded conjugate export pump in human kidney proximal tubules and in renal cell carcinoma.

Human kidney proximal tubule epithelia express the ATP-dependent export pump for anionic conjugates encoded by the MRP2 (cMRP/cMOAT) gene (symbol ABCC2). MRP2, the apical isoform of the multidrug resistance protein, is an integral membrane glycoprotein with a molecular mass of approximately 190 kD that was originally cloned from liver and localized to the canalicular (apical) membrane domain of hepatocytes. In this study, MRP2 was detected in human kidney cortex by reverse transcription-PCR followed by sequencing of a 826-bp cDNA fragment and by immunoblotting using two different antibodies. Human MRP2 was localized to the apical brush-border membrane domain of proximal tubules by double and triple immunofluorescence microscopy including laser scanning microscopy. The expression of MRP2 in renal cell carcinoma was studied by reverse transcription-PCR and immunoblotting in samples from patients undergoing tumor-nephrectomy without prior chemotherapy. Clear-cell carcinomas, originating from the proximal tubule epithelium, expressed MRP2 in 95% (18 of 19) of cases. Immunofluorescence microscopy of MRP2 in clear-cell carcinoma showed a lack of a distinct apical-to-basolateral tumor cell polarity and an additional localization of MRP2 on intracellular membranes. MRP2, the first cloned ATP-dependent export pump for anionic conjugates detected in human kidney, may be involved in renal excretion of various anionic endogenous substances, xenobiotics, and cytotoxic drugs. This conjugate-transporting ATPase encoded by the MRP2 gene has a similar substrate specificity as the multidrug resistance protein MRP1, and may contribute to the multidrug resistance of renal clear-cell carcinomas.

Angiomyolipoma of the kidney and lymph nodes.

Angiomyolipoma (AML) is a benign mesenchymal tumor predominantly occurring in the kidney. Despite its low incidence of 0.07-0.03% in an unselected population, this tumor is well known, because the typical AML can be diagnosed without histological confirmation by a combination of ultrasound (US) and computerized tomography (CT) imaging in up to 95% of cases. In contrast, simultaneous involvement of the kidney and the regional lymph nodes is less known and might be confused with metastasizing malignant tumor. We report a case of the very uncommon simultaneous involvement of the kidney and the lymph nodes in AML.

Prognostic value of p27Kip1 and p21WAF/Cip protein expression in muscle invasive bladder cancer.

Two genes, namely p27Kip1 and p21WAF/Cip1 that reveal distinct structural homology, have been identified as inductors of cell cycle arrest at the G1-checkpoint to prevent entry of somatic cells into the S phase of the cell cycle when substantial DNA damage has occurred. It was demonstrated that the p21WAF/Cip1 gene is induced by pathways dependent and independent from a functionally intact p53 tumour suppressor protein. It has been suggested that decreased expression both of the p21WAF/Cip1 and p27Kip1 protein may contribute to the development of human malignancies due to loss of critical antiproliferative mechanisms. So far, the role of altered p21WAF/Cip1 and mainly of a decreased p27Kip1 protein expression in patients with muscle invasive bladder cancer has not been investigated. In the present study, 50 tumour specimens from 50 patients undergoing radical cystectomy (T2-T4) were investigated for different biological and clinical characteristics as possible prognostic factors: age, depth of tumour infiltration (T-stage), histological grading (G), lymph node status as well as immunohistochemical staining for the p21WAF/Cip1 and p27Kip1 proteins. The median recurrence-free survival for patients with and without retained p21WAF/Cip1 protein expression was 54 months (3-86 months) and 13 months (1-40 months), respectively (p=0.07). During univariate analysis, loss of p21WAF/Cip1 protein expression (p=0.02), T-stage (p=0.02) and histological grading (p=0.03) were significant prognostic factors for survival, among which a negative reaction for the p21WAF/Cip1 protein (p=0.02) as well as T-stage (p=0.005) remained independent significant predictors during multivariate analysis. Loss of p27Kip1 protein expression was not correlated with the recurrence-free or the overall survival of the patients. Prospective studies are needed to confirm the independent prognostic potential of cell-cycle associated proteins such as p21WAF/Cip1 in patients with muscle invasive bladder cancer. The availability of more refined prognostic factors should assist decision making regarding the value of more aggressive treatment options, such as adjuvant or neoadjuvant chemotherapy, for defined subgroups of patients.

Sacral electrical neuromodulation as an alternative treatment option for lower urinary tract dysfunction.

Temporary electrical stimulation using anal or vaginal electrodes and an external pulse generator has been a treatment modality for urinary urge incontinence for nearly three decades. In 1981 Tanagho and Schmidt introduced chronic electrical stimulation of the sacral spinal nerves using a permanently implanted sacral foramen electrode and a battery powered pulse generator for treatment of different kinds of lower urinary tract dysfunction, refractory to conservative treatment. At our department chronic unilateral electrical stimulation of the S3 sacral spinal nerve has been used for treatment of vesi-courethral dysfunction in 43 patients with a mean postoperative follow up of 43,6 months. Lasting symptomatic improvement by more than 50 % could be achieved in 13 of 18 patients with motor urge incontinence (72,2 %) and in 18 of the 21 patients with urinary retention (85,7 %). Implants offer a sustained therapeutic effect to treatment responders, which is not achieved by temporary neuromodulation. Chronic neuromodulation should be predominantly considered in patients with urinary retention. Furthermore in patients with motor urge incontinence, refusing temporary techniques or in those requiring too much effort to achieve a sustained clinical effect. Despite high initial costs chronic sacral neuromodulation is an economically reasonable treatment option in the long run, when comparing it to the more invasive remaining therapeutic alternatives.

High mortality from urothelial carcinoma despite regular tumor screening in patients with analgesic nephropathy after renal transplantation.

Patients with end-stage renal failure due to analgesic nephropathy have an increased risk of developing a urothelial carcinoma. To determine the impact of renal transplantation on the frequency of urothelial carcinomas, we analyzed 2072 patients who underwent 2371 renal transplantation between 1968 and 1993, including 78 (3.8%) with clinically proven analgesic nephropathy. Before and after transplantation a regular tumor screening was performed in patients with analgesic nephropathy by urine cytology and abdominal sonography. In 11 of the 78 patients with analgesic nephropathy (14.1%; age 51-66 years, 40-108 months after initiation of dialysis treatment, 5-77 months after transplantation), a urothelial carcinoma of the native urinary tract, especially the kidneys, was diagnosed. Therapy comprised nephroureterectomy (n = 6), transurethral resection (n = 6) and/or cystectomy (n = 2). Seven patients died due to tumor progression 16.3 (4-33) months postoperatively and one patient died due to a perioperative complication. Despite regular tumor screening after transplantation, the diagnosis of a urothelial carcinoma was made very late, leading to a high tumor-related mortality. As a consequence, we suggest that a bilateral nephroureterectomy should be performed prophylactically in patients with proven analgesic nephropathy. In addition, a cystoscopy with lavage cytology testing of the bladder should be performed twice a year.

Prostate-specific antigen density--a reliable parameter for the detection of prostate cancer?

We compared the prostate-specific antigen density (PSAD) in clinically and surgically staged patients with specimen-confined prostate cancer (n = 57) and in patients with benign hyperplasia (n = 69), who underwent transvesical adenomectomy. The PSAD was calculated from the preoperative PSA level and the specimen volume. The prostate volume was determined by dividing the prostate weight by the specific gravity of the tissue. The mean tissue values used for PSAD calculation were 51.9 g in men with prostate cancer (PCA) and 62.9 g in men with benign prostatic hyperplasia (BPH). The PSAD values showed significant differences (BPH 0.19 versus PCA 0.37, P = 0.029). Receiver operator characteristic (ROC) curves demonstrated the best cutoff value to be 0.15, with the sensitivity being 58%; the specificity, 51% and the positive predictive value of PCA, 49%. At a serum PSA level below 10ng/ml, the best cutoff value was 0.1 and the positive predictive value was 51%. The PSAD results we calculated from an accurate prostate volume (surgical estimate) show that PSAD is not a significant predictor of prostate cancer.

Bilateral metachronous testicular germ cell tumors occurring in two non-twin brothers. Case report and review of the literature.

We report here the familial occurrence of bilateral testicular germ cell tumors in 2 non-twin brothers, developing after an interval of 16 and 4 years, respectively. To our knowledge, this is the first report on the occurrence of metachronous and bilateral testicular tumors in non-twin brothers.

Denovo urothelial carcinoma of the upper and lower urinary tract in kidney--transplant patients with end-stage analgesic nephropathy.

Patients with end-stage analgesic nephropathy bear a higher risk for urothelial cancer than do patients with other renal diseases. In a retrospective study in patients with analgesic nephropathy and kidney transplants we analyzed the prevalence and clinical course of de novo urothelial cancer. Diagnosis of analgesic nephropathy was based on the patients' history and clinical data. Only patients under cyclosporine treatment were included. Between 1968 and 1993, 2,371 kidney transplants were performed on 2,072 patients in the Department of Abdominal and Transplant Surgery. The prevalence of analgesic nephropathy was 3.1%. Of 65 patients with analgesic nephropathy and kidney transplants, 10 (15.4%) developed urothelial carcinoma; 10.8%, bladder cancer; and 9.1%, renal pelvic cancer. The mean age at diagnosis was 56.1 years. Urothelial cancer occurred on average at 33.6 months posttransplantation. On average, 6 of 10 patients with urothelial cancer died of the disease at 16.9 months after the diagnosis. All patients with urothelial bladder cancer had a muscle-infiltrating tumor of moderate or high grade. Since urothelial renal pelvic cancer occurred in 9.1% of our patients with analgesic nephropathy and urological screening is insufficient in patients on dialysis, we suggest that prophylactic nephroureterectomy be performed on one side before transplantation and on the contralateral side at 3-6 months after transplantation. An aggressive approach is indicated in patients with urothelial cancer of the bladder.

Prognostic factors for the postoperative outcome of penile venous surgery for venogenic erectile dysfunction.

Since penile venous surgery is usually associated with a poor postoperative outcome, a study was done to evaluate possible prognostic factors for this procedure. A total of 77 patients with erectile dysfunction underwent ligation of all dorsal penile veins and resection of the deep dorsal penile vein for venous incompetence. In all patients a comprehensive evaluation was done preoperatively. All patients did not respond to pharmacotherapy and had a venous leak. After a followup of 6 months, patients were classified as having full spontaneous erections, failure and response to pharmacotherapy. Of the 77 patients 31 (40.3%) had full spontaneous erections, 8 (10.3%) were currently responding to pharmacotherapy and 38 (49.4%) failed. The maintenance flow was 75 +/- 45 ml. per minute in the group with spontaneous erections and 103 +/- 60 ml. per minute in the failure group (p = 0.20). Mean patient age was 49.8 +/- 11.7 and 49.1 +/- 10.2 years, respectively (p = 0.23). Of the 41 patients wih normal single potential analysis of cavernous electrical activity 28 had full erections postoperatively, 5 responded to pharmacotherapy and 8 failed, compared to 3, 3 and 30, respectively, of the 36 patients with abnormal single potential analysis of cavernous electrical activity. After a mean followup of 21 months (range 6 to 47 months), 4 patients with full erections at 6 months postoperatively currently require intracavernous pharmacotherapy. Our results indicate that single potential analysis of cavernous electrical activity seems to be an important prognostic factor for the postoperative outcome of penile venous surgery for venogenic impotence.

[Metastatic adult teratoma of the testis. Possibilities of chemotherapy and surgical treatment]. / Das metastasierte adulte Teratom des Hodens. Möglichkeiten der chemotherapeutischen und operativen Behandlung.

We report on a patient with the diagnosis of an adult teratoma metastasizing as choriocarcinoma. The 49-year-old man died of dysfunction of the liver caused by massive metastatic involvement. This case demonstrates the malignant potential of adult teratoma and emphasizes the need for chemotherapy of the same kind as for other malignant germ cell tumours if undifferentiated metastases of the teratoma are present. The chemotherapeutic modalities and the options for surgical treatment of metastatic adult teratomas of the testis are discussed.

Intracavernous calcitonin gene-related peptide plus prostaglandin E1: possible alternative to penile implants in selected patients.

The implantation of a penile prosthesis is still the ultima ratio for patients with erectile dysfunction who fail other treatment options such as pharmacotherapy and penile venous surgery. Despite mostly favorable results regarding restoration of erectile capacity, penile allografts are often not accepted for various reasons. Therefore, pharmacotesting with a mixture of calcitonin gene-related peptide and prostaglandin E1 (CGRP/PGE1) was offered to different selected patients populations: 28 patients with erectile dysfunction and venous leakage who failed penile venous surgery, 28 patients with erectile dysfunction and venous leakage (who refused penile venous surgery) and 12 patients without venous leakage, but poor response to maximum doses of papaverine/phentolamine, received 5 micrograms CGRP plus 10 micrograms PGE1. Erections sufficient for intercourse were noted in 19/28 (67.9%), 20/28 (71.4%) and 11/12 (91.7%) patients, respectively. Our data show that a combination of CGRP and PGE1 may be an alternative to penile implants in selected patients.