Pelvic exenteration for recurrent or advanced gynecologic malignancies - Analysis of outcome and complications.

Pelvic exenterations are known to be a last resort therapeutic option for advanced or recurrent gynecologic malignancies, which are known to have poor prognosis. All women treated with anterior (APE) or total (TPE) pelvic exenteration at our University hospital within a five-year period were identified and their data retrospectively analysed. Parameters such as demographic information, tumor type and stage, previous therapy as well as complication rate and overall survival were evaluated. 47 women were enrolled in this study. Most common indication for PE was cervical cancer (51.1%) followed by carcinoma of the vagina (17%), vulva (10.6%), endometrium (8.5%), ovaries (4.3%) and uterus (2.1%). Patients had received 1, 2 or 3 treatment modalities prior in 12.8%, 38.8% and 21.2% respectively. Predominant urinary diversion was ileum conduit (75.5%). Major complications (Clavien Dindo ≥ III) were observed in 40.4%, none in 19.2%. Early mortality was 4.3%. Median Overall Survival (mOS) was 14 months with 2- and 3-year survival rates of 38.8% and 21.2% respectively. After a median follow up of 47 months, 25.5% were still alive. Excluding patients with metastatic disease (n = 10), mOS was 20.6 months with 2- and 3-year survival rates of 46% and 35.2%. OS was significantly worse for patients with positive margins (p = 0.003). Receiving neoadjuvant treatment (25.5%) correlated with negative margins (p = 0.013) but not with overall survival. PE is feasible with acceptable complication and mortality rates. The long-time benefit is notable bearing in mind the extensive nature of the malignancies and the procedure undertaken.

[Follow-up of bladder cancer : The right examinations at the right time]. / Tumornachsorge des Harnblasenkarzinoms : Die richtigen Untersuchungen zum richtigen Zeitpunkt.

Schedules for the follow-up (FU) of bladder cancer patients are predominantly based on studies with low level of evidence and the resulting guidelines' recommendations that are often founded on expert consensus. FU of non-muscle invasive bladder cancer (NMIBC) includes cystoscopy and cytology as standard, and imaging modalities to a lower extent. FU of muscle-invasive bladder cancer (MIBC) depends primarily on the therapeutic modality chosen and on the stage of disease. In this scenario, FU is complemented by functional and quality of life related aspects. These apply even more for FU in palliative situations. Here, the individual focus is on examinations that might have a consequence in terms of survival and/or symptom relief.

[Big surprise in the lesser pelvis]. / Große Überraschung im kleinen Becken.

A 17-year-old young man presented at our clinic with asymptomatic microhematuria. Ultrasonography and computer tomography found an intraperitoneal lesion of unknown dignity located on top of the bladder. Surgical exploration and histological examination confirmed the diagnosis of a secondary pelvic spleen, a lien bipartitus.

[Renal and ureteral injuries. Diagnosis and treatment]. / Nieren- und Ureterverletzungen. Diagnostik und Therapie.

BACKGROUND: In severely injured patients, urologic trauma is diagnosed in about 10 % of patients. Renal trauma is most common, while ureteral trauma is in the majority of cases iatrogenic. These two urologic injuries influence the clinical course, morbidity, and mortality. Thus, rapid identification, sufficient diagnostic workup, and adequate therapy of renal and ureteral injuries are essential. THEME: This article reviews the actual diagnostic procedures, classification, and stage-dependent therapy options in renal and ureteral injuries.

[News with clinical relevance from major scientific meetings 2015--Update Urooncology]. / Was gab es Neues auf den Kongressen 2015?--Update Uroonkologie.

What new developments in urooncology were discussed at the 2015 annual meetings of ASCO, EAU, DGU and ESMO? This review summarises news relevant to the daily diagnosis and treatment of prostate, bladder and kidney cancer. While study results seem to change paradigms in the treatment of prostate cancer, particularly in metastatic but still hormone-sensitive stages, immunotherapeutic strategies for the treatment of kidney and urothelial cancer are very promising and might expand the systemic therapeutic options in the years to come.

[Operative interventions of urologic traumata in severe injured patients in the acute phase]. / Operative Interventionen urologischer Verletzungen beim schwerverletzten Patienten in der Akutphase.

INTRODUCTION: The frequency of urological traumata and the need for interventions in severely injured patients in Germany are unknown. The aim of this study was to determine the frequency of urological traumata in about 90,000 severely injured patients (Injury Severity Score, ISS ≥ 16). MATERIALS AND METHODS: Data of 90,000 patients from the TraumaRegister DGU® were retrospectively analyzed. All patients with an ISS of ≥ 16 were included. The kind of urological traumata and the need for urological intervention within 24 hours were assessed, as well as the kind of accident, additional traumata and the clinical course. RESULTS: 48,797 patients fulfilled the inclusion criteria. Urological trauma was existent in 7.1 %, especially in men (78 %). Kidneys were affected most frequently (4.8 %) compared to ureters (0.2 %), urinary bladder (1.2 %), urethra (0.5 %) and genitals (0.4 %). Traffic accidents and falls from higher levels represented the main cause for urological traumata (> 90 %). It was associated with additional pelvis, thorax and abdomen traumata (each 7.1 %) and showed a distinct increase dependent on the abbreviated injury scale (AIS). Ureter (10.6%) and urethra (6.3%) trauma was deferred diagnosed most, this was associated with a higher rate of urological operations. The general duration of hospital stay and that in the intensive care unit were prolonged by urological traumata. DISCUSSION: The data showed the prevalence of urological trauma in severely injured patients analyzed in a huge patient cohort of the TraumaRegister DGU®. For the first time the number, degree and medical care in the reality of urological traumata in severely injured patients were available.

Does visualisation during urethrocystoscopy provide pain relief? Results of an observational study.

BACKGROUND: To measure the effects of real-time visualisation during urethrocystoscopy on pain in patients who underwent ambulatory urethrocystoscopy. METHODS: An observational study was designed. From June 2012 to June 2013 patients who had ambulatory urethrocystoscopy participated in the study. In order to measure pain perception we used a numeric rating scale (NRS) 0 to 10. Additional data was collected including gender, reason for intervention, use of a rigid or a flexible instrument and whether the patient had had urethrocystoscopy before. RESULTS: 185 patients were evaluated. 125 patients preferred to watch their urethrocystoscopy on a real-time video screen, 60 patients did not. There was no statistically relevant difference in pain perception between those patients who watched their urethrocystoscopy on a real-time video screen and those who did not (p = 0.063). However, men who were allowed to watch their flexible urethrocystoscopy experienced significantly less pain, than those who did not (p = 0.007). No such effects could be measured for rigid urethrocystoscopy (p = 0.317). Furthermore, women experienced significantly higher levels of pain during the urethrocystoscopy than men (p = 0.032). CONCLUSIONS: Visualisation during urethrocystoscopy procedures in general does not significantly decrease pain in patients. Nevertheless, men who undergo flexible urethrocystoscopy should be offered to watch their procedure in real-time on a video screen. To make urethrocystoscopy less painful for both genders, especially for women, should be subject to further research.

[News with clinical relevance from major scientific meetings 2014 - Update Urooncology]. / Was gab es Neues auf den Kongressen 2014? - Update Uroonkologie.

What is new in urooncology in the year 2014? This review gives a brief but comprehensive overview of new developments in diagnosis and treatment of localized as well as advanced prostate, bladder and kidney cancer which have been presented on the occasion of the annual meetings of the European and American urologic and oncological associations in 2014. Attention is particularly directed to those data and results from trials which might be of direct or indirect clinical relevance.

[Indications for nephron-sparing surgery. Analysis over a 13-year period in the context of changing guidelines]. / Indikationsstellung zur organerhaltenden Nierentumorchirurgie. Analyse eines 13-Jahres-Zeitraums vor dem Hintergrund sich wandelnder Leitlinien.

BACKGROUND: The indications for nephron-sparing surgery have been considerably extended by guideline recommendations in recent years. It remains unclear whether clinical practice still reflects these new guidelines. OBJECTIVE: In this retrospective, monocentric analysis at a tertiary referral center the indications for partial nephrectomy over a 13-year period were evaluated. METHODS: In a retrospective database analysis all cases of surgically treated renal masses from 2001 to 2013 were evaluated. Besides demographic, tumor-specific and perioperative variables the development of the surgical technique depending on the tumor stage was evaluated. RESULTS AND DISCUSSION: The proportion of nephron-sparing surgery cases increased from below 20 % in 2001 to 35 % in 2013 in the entire cohort. For stage T1a tumors, partial nephrectomy increased from approximately 50 % to over 90 % and for T1b tumors it rose from 10 % to 50 %. Logistic regression revealed stage 1 tumors to be predictive of partial nephrectomy over the complete evaluation period. Extending the indications for partial nephrectomy even to higher stages is under discussion but not yet supported by data from prospective, controlled studies.

[Metastasized renal cell carcinoma. Measurement of plasma levels of the tyrosine kinase inhibitors sunitinib, sorafenib and pazopanib]. / Metastasiertes Nierenzellkarzinom. Bestimmung der Plasmaspiegel der Tyrosinkinaseinhibitoren Sunitinib, Sorafenib und Pazopanib.

BACKGROUND: Several tyrosine kinase inhibitors (TKI) are used in the treatment of metastasized renal cell carcinoma (mRCC). This article presents a feasibility study for the measurement of plasma levels of sunitinib, sorafenib and pazopanib using liquid chromatography tandem mass spectrometry (LC-MS/MS). METHODS: A total of 23 patients suffering from mRCC under treatment with sunitinib (n=16), sorafenib (n=3) and pazopanib (n=4) were included. Plasma samples (100 µl) were separated by liquid chromatographic analysis and the plasma levels of the TKIs determined by tandem mass spectrometry. RESULTS: The plasma levels of sunitinib, sorafenib and pazopanib were measurable and the results reproducible. During storage of the plasma samples for 1 week at 4°C no significant decrease of the initial concentration was found. The highest plasma levels detected were 99 ng/ml for sunitinib, 9.8 µg/ml for sorafenib and 63 µg/ml for pazopanib. We could show variability in plasma levels according to changes in dosage of TKIs or during treatment-free intervals. CONCLUSION: Measurement of TKI plasma levels using LC-MS/MS is feasible. Further clinical studies have to be conducted to examine if there are any threshold levels for the incidence of adverse events or response to treatment.

[Regional conventions: still up-to-date?]. / Sind Regionalkongresse noch zeitgemäß?

This article poses the question whether regional meetings are still contemporary for continuing medical education using the example of this year's joint meeting of the Vereingung der Mitteldeutschen Urologen e. V. and the Sächsischen Gesellschaft für Urologie e. V., which took place in Marburg from May 22nd - 24th , 2014. It gives an overview of the most important and interesting topics of the meeting and highlights the advantages of regional meetings in comparison to other kinds of medical education possibilities such as national conventions or internet-based courses. The authors conclude that in spite of a significant financial costs and organisational effort, regional meetings contain unique and favourable characteristics and hence should remain a permanent feature of the scientific landscape in Germany.

[Update Urooncology: News with clinical relevance from major scientific meetings 2013]. / ASCO, ESMO, AUA, EAU, DGU - Update Uroonkologie - Was war klinisch relevant auf den Kongressen 2013?

What is new in urooncology in the year 2013? This review gives a brief but comprehensive overview of new developments in diagnosis and treatment of localized as well as advanced prostate, bladder and kidney cancer which have been presented on the occasion of the annual meetings of the European and American urologic and oncological associations in 2013. Attention is particularly directed to those data and results from trials which might be of direct or indirect clinical relevance.

[How can young academics be recruited? Acceptance and effects of urological practice-oriented training]. / Nachwuchs gewinnen - aber wie? : Akzeptanz und Effekte eines urologischen Praxistrainings.

BACKGROUND: There is an increasing lack of young doctors in German hospitals, including urology departments. The aim of this study was to evaluate the benefit of urology practice-oriented courses for German students in a skills laboratory with respect to acceptance, learning success and enthusiasm of the students for urology. METHODS: Transurethral catheterization, digital rectal examination and kidney/bladder sonography were trained in the urology course. Using a 12-point questionnaire, acceptance and quality of the training were evaluated. Learning success was checked using a urological OSCE-station (Objective Structured Clinical Examination). Additionally, participants were questioned on interest in urology and the consideration of future work in the field (medical elective or practical year). RESULTS: A total of 147 questionnaires from 190 participating students were suitable for analysis. Acceptance and quality of training were highly ranked accompanied by a very satisfying objective and subjective learning success. Interest for urology was stimulated in 98.4 % and future work in urology was imaginable for 60.4 % of the students. DISCUSSION: Practice-oriented urology student courses show high acceptance, high learning success and increase of attractiveness of urology. The training of urological skills represents a sufficient tool to entice students for urology and is helpful in enhancing the future of urology.

[Predictors for presence of residual tumor in follow-up transurethral resection of bladder tumors: single center results]. / Vorhersageparameter für das Vorliegen eines Residualtumors bei der TUR-B-Nachresektion: single-center-Ergebnisse.

BACKGROUND: European Association of Urology (EAU) guidelines recommend a follow-up transurethral resection of bladder tumors (reTUR-B) for intermediate and high-risk non-muscle invasive bladder cancer (NMIBC) 2-6 weeks after the initial resection. The purpose of this study was to find parameters which indicate the presence of residual tumor in reTUR-B and to evaluate the prognostic value. PATIENTS AND METHODS: The data from all patients treated with TUR-B between January 2005 and December 2008 were retrospectively evaluated. The residual tumor rate was correlated with age, sex, staging, grading, risk group, multifocality and surgeon's level of training. RESULTS: A total number of 555 TUR-B operations were carried out and 179 patients received reTUR-B according to the EAU guidelines. Age (p=0.8), sex (p=0.7), initial staging (p=0.2), initial grading (p=0.3) and surgeon's level of training (p=0.7) did not have an impact on the rate of residual tumor in reTUR-B. Tumors categorized as high risk according to the EAU risk score in initial TUR-B (p<0.01) and multifocality (p=0.01) were associated with significantly higher rates of residual tumor. CONCLUSIONS: A reTUR-B is strongly indicated in high risk bladder tumors as well as multifocal tumors showing a significantly increased residual tumor rate. Other clinical parameters showed no prognostic value for the existence of residual tumor in reTUR-B.

[Update urooncology: news with clinical relevance from major scientific meetings 2012]. / Update Uroonkologie: Was war klinisch relevant auf den Kongressen 2012?

What is new in urooncology in the year 2012? This review gives a brief but comprehensive overview of new developments in diagnosis and treatment of localized as well as advanced prostate, bladder and kidney cancer which have been presented on the occasion of the annual meetings of the European and American urologic and oncological associations in 2012. Attention is particularly directed to those data and results of trials which might be of direct or indirect clinical relevance.

[DGFIT: Immune and targeted therapy in urologic oncology ­ what can be expected?]. / DGFIT: Immun- und Targeted Therapie in der Uroonkologie ­ was können wir erwarten?

Immune and targeted therapy represent innovative therapy options in oncology. An overview of novel immune and targeted therapy options in urologic oncology presented at the most recent scientific urological and oncological meetings is given by representatives of the German Association of Immune and Targeted Therapy (DGFIT). Besides renal cell cancer, where targeted therapy is well established, new immune and targeted approaches in prostate and bladder cancer are discussed, summarizing current results and new developments with relevant impact for the treating physician.

[Transobturatoric sling procedures for stress urinary incontinence in elderly women: indication and results]. / Transobturatorische Bandplastiken in der Inkontinenztherapie bei älteren Patientinnen : Indikation und Ergebnisse.

Urinary incontinence is one of the great challenges in geriatrics. The prevalence is high in elderly women and increases continuously with increasing age. The consequences of incontinence can be severe and are often associated with social isolation. Placement of a transobturatoric sling is a frequently used option in the surgical treatment of stress incontinence. Continence rates are high and associated with low side effects but several sub-analyses have shown poorer success rates and an increase in perioperative morbidity in women over 70 years. Recent studies, however, point to similarly good success rates and thus provide an effective and safe treatment option.

[Multiparametric MRI, elastography, contrastenhanced TRUS. Are there indications with reliable diagnostic advantages before prostate biopsy?]. / Multiparametrisches MRT, Elastographie, kontrastmittelverstärkter Ultraschall. Gibt es Indikationen mit verlässlichem diagnostischem Zugewinn vor Prostatastanzbiopsie?

Prostate cancer (PCA) is the most common malignancy in men with an increasing incidence and is responsible for about 11,000 deaths per year in Germany. Fortunately, the mortality of PCA has decreased in recent years despite the rising incidence reflecting improvements in diagnostic methods. Many new innovations in imaging techniques for PCA are available and may be helpful in early detection of PCA. Contrast-enhanced sonography, computer-assisted sonography, elastography and multiparametric magnetic resonance imaging (MRI) seem to be the most promising methods to increase the detection rate of PCA during diagnostic work-up. The value of these new innovative techniques concerning improvement in PCA detection is reviewed.

[Choline PET/CT in the diagnosis of primary and recurrent prostate cancer. Are there evidence-based indications?]. / Das Cholin-PET/CT in der Primär- und Rezidivdiagnostik des Prostatakarzinoms. Gibt es evidenzbasierte Indikationen?

Overdiagnosis and resulting overtreatment in prostate cancer are under intensive discussion both in the urologic communities and in the public media. Sensitive and specific diagnostic modalities could be one step forward to overcome this problem. Choline PET/CT provides fusion imaging that combines anatomical/morphological information with metabolic/functional data. Despite promising preclinical data and interesting initial clinical results, this cost-intensive and logistically demanding technology has not yet found its way into routine clinical practice; the German and European guideline recommendations are careful and reluctant. This review has the goal to give an overview of the recent data both on initial diagnosis and on staging/diagnosis for biochemical recurrence by choline PET/CT and to summarize the possible role of this innovative technology in the future, if adequate research projects can be realized.