[Fistulas of the urogenital tract after radiotherapy]. / Fisteln des Urogenitaltraktes nach Strahlentherapie.

BACKGROUND: Radiotherapy plays a substantial role in the treatment of malignancies. More than 2/3 of all oncologic patients undergo radiotherapy during their specific treatment. Besides manifold side effects of radiotherapy, radiogenic fistulas of the urogenital tract are a potential severe complication. These fistulas might affect the female genital tract and the urinary tract. THERAPY: Potential manifold variety of radiogenic urogenital fistulas requires a specific therapy. Radiation tissue damage includes severely disturbed local blood supply. Consequently, in some cases extremely complex reconstructive techniques are necessary to restore the functionality of the urinary tract. CONCLUSION: The treatment of radiogenic urogenital fistulas is challenging. A successful therapy can only be achieved by local improvement of the blood supply in the damaged area.

Mucin-Poor Mucinous Tubular and Spindle Cell Carcinoma of the Kidney Presented with Multiple Metastases Two Years after Nephrectomy: An Atypical Behaviour of a Rare, Indolent Tumour.

BACKGROUND: Mucinous tubular and spindle cell carcinoma (MTSCC) is a rare type of renal cell carcinoma, whose clinical behaviour and metastatic potential have not been fully elucidated to date. There are only a few metastatic cases in the literature, which all either featured sarcomatoid differentiation or were synchronously metastasised at diagnosis. CASE PRESENTATION: We report a case of a 49-year-old male with end-stage kidney disease on dialysis, presenting with multiple osseous metastases of a mucin-poor variant of MTSCC of the kidney, without sarcomatoid differentiation, two years after bilateral nephrectomy for papillary renal cell carcinoma (RCC) at a curable stage. After retrospectively reexamining the initial nephrectomy specimens, the tumour of the right kidney was also diagnosed as a mucin-poor variant of MTSCC, while the tumour of the left kidney was confirmed as a papillary RCC. CONCLUSIONS: It is proposed that MTSCC can be associated with end-stage renal disease and that particularly the mucin-poor variant is easily confused with papillary renal cell carcinoma, as happened in this case. Although it is considered as a relatively indolent malign entity, it can metastasise even years after successful primary surgical treatment. This implies, besides accurate diagnosis, that MTSCC patients should be monitored closely in the follow-up period.

[Treatment of long-term radiation injuries in the urinary tract]. / Therapie von Strahlenspätschäden am Harntrakt.

BACKGROUND: Radiotherapy plays a substantial role in the treatment of malignancies. The side effects and long-term sequelae of radiotherapy are manifold and depend on the single doses and the total dosage, the time interval between two doses, the size of the irradiated tissue area and the radiation sensitivity of individual tissues. The urological complications following radiotherapy include inflammatory alterations of the bladder (radiation-induced hemorrhagic cystitis), fibrosis with subsequent radiogenic shrunken bladder, stenosis of the ureter and formation of secondary retroperitoneal fibrosis. In addition, the formation of necrosis can result in rectourethral, uterovaginal and vesicovaginal fistulas up to formation of a cloaca. THERAPY: The main problem following radiotherapy is microangiopathy in the irradiated area. The therapy of radiation injuries in the urogenital tract depends on the extent and localization of the radiation damage. In particularly severe cases extremely complex reconstructive techniques are necessary for restoration of functionality of the urinary tract and preservation of renal function. CONCLUSION: Radiation injuries can remain asymptomatic for a long time so that a closely controlled urological surveillance is indispensable. The correct selection of the intestinal segments for surgical removal of radiation injuries in the urogenital tract is of pivotal importance.

[Management and prevention of complications in open urethral surgery. End-to-end anastomosis and buccal mucosa urethroplasty]. / Management und Prävention von Komplikationen bei offener Harnröhrenchirurgie. End-zu-End-Anastomose und Mundschleimhauturethroplastik.

Open operative procedures for urethral reconstruction (i.e. stricture resection with primary end-to-end anastomosis and buccal mucosa urethroplasty) are established and proven techniques with a low complication profile and high success rates. The aim of this operative technique is removal of the urethral obstruction to avoid far-reaching complications for the whole urinary tract. Despite excellent long-term results, complications are not completely avoidable in both techniques. A successful complication management requires the complete spectrum of reconstructive techniques in addition to appropriate operative expertise in order to be able to achieve the optimal result even in cases of complications. Simultaneously the recognition of potential risks contributes to a further reduction of early and delayed complications both in the approach to the operative intervention as well as intraoperatively.

Clinical and pathological nodal staging score for urothelial carcinoma of the bladder: an external validation.

PURPOSE: Radical cystectomy (RC) and pelvic lymph node dissection (LND) are standard treatments for muscle-invasive urothelial carcinoma of the bladder. Lymph node staging is a prerequisite for clinical decision-making regarding adjuvant chemotherapy and follow-up regimens. Recently, the clinical and pathological nodal staging scores (cNSS and pNSS) were developed. Prior to RC, cNSS determines the minimum number of lymph nodes required to be dissected; pNSS quantifies the accuracy of negative nodal staging based on pT stage and dissected LNs. cNSS and pNSS have not been externally validated, and their relevance for prediction of cancer-specific mortality (CSM) has not been assessed. METHODS: In this retrospective study of 2,483 RC patients from eight German centers, we externally validated cNSS and pNSS and determined their prediction of CSM. All patients underwent RC and LND. Median follow-up was 44 months. cNSS and pNSS sensitivities were evaluated using the original beta-binominal models. Adjusted proportional hazards models were calculated for pN0 patients to assess the predictive value of cNSS and pNSS for CSM. RESULTS: cNSS and pNSS both pass external validation. Adjusted for other clinical parameters, cNSS can predict outcome after RC. pNSS has no independent impact on prediction of CSM. The retrospective design is the major limitation of the study. CONCLUSIONS: In the present external validation, we confirm the validity of both cNSS and pNSS. cNSS is an independent predictor of CSM, thus rendering it useful as a tool for planning the extent of LND.

Oncological outcome of primary versus secondary muscle-invasive bladder cancer is comparable after radical cystectomy.

BACKGROUND: High-risk non-muscle-invasive bladder cancer (NMIBC) progressing to muscle-invasive bladder cancer (MIBC) is associated with adverse tumour biology. It is unclear, however, whether outcome of NMIBC progressing to MIBC is adverse compared to primary MIBC and whether NMIBC of higher risk of progression to MIBC is adverse compared to NMIBC of lower risk. OBJECTIVE: Our objective was to assess cancer-specific survival (CSS) following radical cystectomy (RC) for primary MIBC and for NMIBC progressing to MIBC in dependence of EORTC risk score. MATERIALS AND METHODS: Clinical and histopathological characteristics and CSS of 150 patients were assessed. Secondary MIBCs were stratified by EORTC risk score at the last transurethral resection of bladder tumour for NMIBC. RESULTS: CSS did not differ significantly between primary and secondary MIBC (p = 0.521). Secondary MIBC with high EORTC score had significantly shorter CSS compared to secondary MIBC with intermediate EORTC score (p = 0.029). In multivariable analysis, pathological tumour stage (HR = 3.77; p = 0.020) and lymph node stage (HR = 2.34; p = 0.022) were significantly correlated with CSS. CONCLUSION: While the outcome of secondary MIBC is not generally adverse compared to primary MIBC, the EORTC risk score not only reflects high risk of progression of NMIBC to MIBC, but also worse outcome following RC for secondary MIBC. Timely RC should thus be debated in high-risk NMIBC.

[Use of bowel segments for ureter reconstruction]. / Harnleiterersatz unter Verwendung von Darmsegmenten.

When ureter damage is extensive or affects the midureter continuity can be restored using bowel segments. The principle issues of these techniques comprise reconstruction of the urinary tract preserving renal function in a long-term setting. The safety of ureters reconstructed from bowel segments has been validated in several large series as a reliable last resort solution with favorable results and low complication rates. Ureter reconstruction with bowel segments is doomed to fail in patients with short-bowel syndrome or Crohn's disease. Furthermore, the applicability in children and patients with progressive renal deficiency is severely limited. To prevent renal deterioration the use of retubularized bowel segments as a substitute for ureter defects has been postulated. Whereas antirefluxive implantation seems unnecessary in patients with a native bladder in situ or orthotopic bladder substitution, it is recommended in continent bowel reservoirs with cutaneous stoma.

Urinary incontinence due to the presence of necrotic adult Schistosoma haematobium parasite in the bladder following travel to Egypt.

A case of seronegative urinary Schistosomiasis is reported in a 68-year-old Caucasian male presenting with urgency of micturition and incontinence several months after bathing in a chlorinated pool of a first class hotel in Egypt. The symptoms were initiated by a necrotic adult Schistosoma haematobium parasite found in the urinary bladder following a cystoscopic examination. The purpose of this report is to describe this probable and uncommon source of Schistosomiasis, to demonstrate that Schistosoma parasites can also be found in the urinary bladder and to emphasize the importance of travel history.

[Insufficiency of the efferent segment in continent cutaneous diversion]. / Das inkompetente Nabelstoma.

Besides common requirements like universal applicability, reproducibility, and low complication rate, functionality and cosmetic aspects are essential in continent cutaneous diversions. Creation of the continence mechanism certainly represents the major surgical challenge in continent cutaneous diversions. Complete continence and ease of catheterization are mandatory for the patient's quality of life.High surgical competence, creativity, and variability are required in cases of revisional surgery for stomal insufficiency. In addition to accurate preoperative clinical, endoscopic, and radiologic evaluation, extensive expertise in the fields of continent urinary diversion and reconstructive urology allows performance of a surgical solution ideally adapted to the patient's individual situation. Between January 1990 and September 2011 we performed urinary diversion in 1,224 patients (mean follow-up 90.3 months). Continent urinary diversion was performed in 717 patients (59%); in 486 patients an ileocecal reservoir with continent cutaneous diversion, in 186 patients an ileocecal neobladder, and in 45 patients a sigma rectum pouch was created. Incontinence rate and stenosis rate in patients with appendico-umbilical stoma (n=219) were 2.3% and 10% and in patients with intussuscepted ileum nipple (n=267) nipple 5.2% and 2.7%. Stenosis usually can be corrected easily by simple excision of the obstructive scarred tissue or by stomal reconfiguration. Outlet failure may result from simple causes like fistula formation between reservoir and efferent segment or skin and nipple gliding or prolapse which can easily be repaired. More complex situations might require creation of a secondary continence mechanism. In our series of 486 patients having undergone continent cutaneous diversion in our department, 14 patients (appendico-umbilical stoma n=5, ileal nipple n=9) suffered from irreversible damage of the continent outlet. In 11 patients creation of a secondary intussuscepted ileal nipple and in 3 patients a modified Managadze procedure was performed.In case of absence of the ileocecal valve (e.g. in primary ileal reservoirs, ileocolonic reservoirs without integrated ileocecal valve) and in case of a preexisting pouch of small capacity we prefer augmentation of the primary reservoirs with an ileocecal cup patch plasty in combination with the submucosally embedded appendix or intussuscepted ileal nipple serving as continent outlet. In our institution this was done in four patients who had undergone primary surgery elsewhere.

[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.

[Urethro-crural fistula to the adductor canal. Late complication following radiotherapy for recurrent prostate cancer]. / Urethrokrurale Fistel zum Adduktorenkanal. Spätfolge einer perkutanen Radiatio eines Prostatakarzinomrezidivs.

Urinary fistulas are rare (late) complications following radiotherapy for prostate cancer. We present the case of a urethro-crural fistula to the adductor canal 7 years after radiotherapy in a man who had previously undergone radical prostatectomy.

[Recto-vesico-cutaneous fistula following salvage cryotherapy of the prostate due to recurrent localized prostate cancer]. / Rektovesikokutane Fistel nach Salvagekryotherapie bei lokalem Prostatakarzinomrezidiv.

For patients with recurrent prostate cancer after initial external beam radiation salvage cryotherapy is considered as an alternative to salvage prostatectomy. We report a serious complication of salvage cryotherapy in a 72-year-old man suffering from a severe recto-vesico-cutaneous fistula 6 weeks after salvage cryotherapy. To manage this situation salvage cystoprostatectomy and continent urinary diversion with creation of an ileocaecal pouch with cutaneous stoma had to be performed.

Urological complications of laparoscopic inguinal hernia repair: a case series.

OBJECTIVES: To illustrate urological complications of laparoscopic inguinal hernia repair and discuss their management. PATIENTS: Between April 2002 and February 2004, four men (aged 38-63 years) were treated for serious complications 2 days to 11 years after unilateral (1 patient) or bilateral (3 patients) laparoscopic inguinal hernioplasty. RESULTS: In all cases (extra and intraperitoneal bladder injury, purulent urocystitis due to mesh-erosion of the bladder, secondary retroperitoneal fibrosis) open revision with complete drainage of the urinary tract was chosen as an efficacious therapeutic strategy. CONCLUSIONS: Awareness of rare complications of laparoscopic inguinal hernia repair may lead to early diagnosis and appropriate management.

[Interventional and surgical treatment of urethral strictures. End-to-end anastomosis]. / Interventionelle und operative Behandlung der Harnröhrenenge: End-zu-End-Anastomose.

Excision with primary anastomosis is an excellent reconstructive option for short bulbar and membranous urethral strictures. With adequate patient selection including history, physical examination, and radiographic staging success rates between 90 and 95% in appropriately selected patients can be achieved. Success with this reliable method is based on adequate excision of the complete urethral stricture and sufficient mobilization of the urethra with tension-free anastomosis. Complications affecting ejaculation or penile sensitivity are rare and might be avoided by appropriate surgical techniques. Resection of the stricture and urethral end-to-end anastomosis represents the "gold-standard" in the treatment of bulbar and membraneous strictures up to a length of 3 cm.

[Renal transplantation and urinary diversion]. / Nierentransplantation und Harnableitung.

For patients with end-stage renal disease and dysfunctional or absent lower urinary tract, complex therapeutic strategies are necessary combining kidney transplantation and - if possible - continent urinary diversion. In this concept urinary diversion is the first step in a two-stage procedure followed by renal transplantation. Meticulous preoperative diagnostics, careful patient selection and life-long close surveillance are critical for the success of this concept. The published data concerning long-term graft and patient survival are promising.

[Ureter triplex with non-functioning upper pole due to ectopic ureterocele and refluxive third ureter bud : case report and review of the literature]. / Ureter triplex mit afunktionellem Oberpol bei ektoper Ureterozele und refluxiver dritter Ureterknospe : Fallbericht und Literaturübersicht.

We present the case of an 8-month-old boy with ureter triplication on the left side with non-functional upper pole due to ectopic ureterocele and a refluxive third ureter bud. We performed an upper pole heminephroureterectomy with resection of the ureterocele and of the refluxive third ureter bud and reimplantation of the lower pole ureter using the psoas hitch technique.