Management of Germ Cell Tumours of the Testes in Adult Patients: German Clinical Practice Guideline, PART II - Recommendations for the Treatment of Advanced, Recurrent, and Refractory Disease and Extragonadal and Sex Cord/Stromal Tumours and for the Management of Follow-Up, Toxicity, Quality of Life, Palliative Care, and Supportive Therapy.

OBJECTIVES: We developed the first German evidence- and consensus-based clinical guideline on diagnosis, treatment, and follow-up of germ cell tumours (GCT) of the testes in adult patients. We present the guideline content in 2 separate publications. The present second part summarizes therecommendations for the treatment of advanced disease stages and for the management of follow-up and late effects. MATERIALS AND METHODS: An interdisciplinary panel of 42 experts including 1 patient representative developed the guideline content. Clinical recommendations and statements were based on scientific evidence and expert consensus. For this purpose, evidence tables for several review questions, which were based on systematic literature searches (last search in March 2018), were provided. Thirty-one experts, who were entitled to vote, rated the final clinical recommendations and statements. RESULTS: Here we present the treatment recommendations separately for patients with metastatic seminoma and non-seminomatous GCT (stages IIA/B and IIC/III), for restaging and treatment of residual masses, and for relapsed and refractory disease stages. The recommendations also cover extragonadal and sex cord/stromal tumours, the management of follow-up and toxicity, quality-of-life aspects, palliative care, and supportive therapy. CONCLUSION: Physicians and other medical service providers who are involved in the diagnostics, treatment, and follow-up of GCT (all stages, outpatient and inpatient care as well as rehabilitation) are the users of the present guideline. The guideline also comprises quality indicators for measuring the implementation of the guideline recommendations in routine clinical care; these data will be presented in a future publication.

[Social medical/public health assessment of the ability to work regarding urological and urooncological diseases]. / Sozialmedizinische Begutachtung der Arbeits- und Erwerbsfähigkeit bei urologischen/uroonkologischen Erkrankungen.

The primary objectives of modern urooncological treatment concepts are quality of life, reintegration and participation. Urological rehabilitation supports the overcoming of side effects of disease and treatment, which is necessary for the timely return to work life. Social medical assessment reflects the individual overall results of the entire treatment process concerning oncological prognosis, physical and mental capacity and resilience.

[Social medicine assessment after surgical and targeted treatment of renal cell cancer]. / Sozialmedizinische Begutachtung nach operativer und zielgerichteter Therapie des Nierenzellkarzinoms.

In Germany, renal cell cancer counts for 2.5 % of all carcinomas in women and 3.5 % in men. Curative therapy ensures good chances of recovery. But there might be permanent complications like renal insufficiency, pain, incisional hernia, flank muscle relaxation, and paresis. In addition, targeted therapy is associated with several potential side effects. In both therapy groups, severe psychological problems may occur. Still employed patients with these problems must be examined by an expert to estimate the possibilities of returning to working (positive scope of work) and occupations which can not be performed anymore (negative scope of work).

[Social medical/public health assessment of bladder cancer after curative and adjuvant therapy]. / Sozialmedizinische Begutachtung nach kurativer und adjuvanter Therapie des Harnblasenkarzinoms.

Radical cystectomy and urinary diversion are a challenge for patients. Requirements for the successful participation of the patient are sufficient urinary diversion management and recuperation/recovery as the result of urological rehabilitation. A social medical assessment reviews the individual oncological prognosis and the rehabilitation results to determine the return to work.

[Social medicine assessment of patients with prostate cancer]. / Sozialmedizinische Begutachtung bei Patienten mit Prostatakarzinom.

Due to the increasing incidence of prostate cancer in social-medicine-relevant age groups, a correct subject-specific evaluation of the professional capacity of these patients with all stages of disease is required. A concluding assessment is only significant when based on concrete functional deficits.

[Specialist uro-oncological rehabilitation after treatment for prostate cancer--update 2015. Position statement of the working group on "rehabilitation of urological and nephrological diseases" of the German Society of Urology with respect to current S3 guidelines]. / Fachspezifische uroonkologische Rehabilitation nach Therapie des Prostatakarzinoms--Update 2015. Positionsbestimmung des Arbeitskreises "Rehabilitation urologischer und nephrologischer Erkrankungen" der DGU vor dem Hintergrund der aktuellen S3-Leitlinie.

After uro-oncological primary therapy of prostate cancer the quality of life of patients is often limited. The adequate and prompt treatment of specific urological functional, physical and mental deficits has a decisive influence on the quality of life. These deficits can be recorded using instruments for measuring the quality of life, in particular the QLQ-C30 of the European Organization for Research and Treatment of Cancer (EORTC) and the SF-36 questionnaires. The quality of life is the most important parameter for quality assurance of the results. The primary objectives are the therapy of postoperative functional disorders, in particular urinary incontinence and erectile dysfunction in addition to overcoming the disease. The "urological triad" plays a central role in recovering the quality of life and patient satisfaction.

[The body concept for prostate carcinoma patients. Development and testing of a questionnaire which ascertains uro-oncological patients' attitudes to their own bodies under the influence of surgery-conditioned consequences]. / Das Körperkonzept von Prostatakarzinompatienten. Entwicklung und Testung eines Fragebogens für die Erfassung von Einstellungen uro-onkologischer Patienten zum eigenen Körper unter den Einfl üssen operationsinduzierter Folgen.

BACKGROUND: The aim of this study is the construction of a questionnaire which determines uro-oncological patients' attitudes to their own bodies. The questionnaire will be tested by means of psychometric criteria for suitability. In this way, the emotional-affective and perceptual--cognitive characteristics of the body concept will be detected more effectively. PARTICIPANTS AND METHODS: For the construction, 12 interviews with patients were conducted and items from four body concept questionnaires were analysed. Subsequently, a draft version, containing 133 items, was written. A total of 305 participants (PCa n=205; healthy n=100) were questioned in 2 studies. Thereafter the suitability of the items could be checked by psychometric and factor analytical criteria. RESULTS: The psychometric testing of the statements led to a selection of the items. 40 items could be established as applicable and were therefore accepted for the final questionnaire. CONCLUSION: The indentified scales show good psychometric characteristics and also differentiate between the healthy and the clinical samples. Preliminary analyses prove the validity of the scales, although this should be subjected to further testing for assurance.

[The patient after radical prostatectomy: complexity and efficiency of a urological rehabilitation program]. / Der Patient nach radikaler Prostatektomie : Leistungsumfang und Leistungsfähigkeit der stationären urologischen Rehabilitation.

Timely physical and mental convalescence and an early recovery of functional side effects belong to an efficient treatment concept for prostate cancer. Every prostate cancer patient has a right to take part in a urological rehabilitation program (Germany). The objectives are continence, potency, overcoming physical complaints, reduction of health risk factors, and psychological support. The results presented show the complexity and efficiency of a urological rehabilitation program.

[Corpus cavernosum rehabilitation after radical urooncological procedures]. / Rehabilitation der Schwellkörperfunktion nach radikalen uroonkologischen Eingriffen.

Corpus cavernosum rehabilitation is an integral part of modern, quality-of-life-oriented urooncological concepts and therefore a basic task of specific urological rehabilitation. Sexual rehabilitation is based on three different therapeutic options: PDE-5 inhibitors, use of corpus cavernosum injection therapy, and use of a therapeutic vacuum device. The indication depends on the status of nerve protection. Close recovery of erectile function is possible.

Colocalization of androgen binding protein, oxytocin receptor, caveolin 1 and proliferation marker p21 in benign prostate hyperplasia.

Androgen-binding protein (ABP) and oxytocin (OT) are among the factors that control smooth muscle proliferation and tumour growth through oxytocin receptor (OTR). A close functional interaction of OTR and caveolin 1 has been shown to modulate cell growth and proliferation. We investigated samples from 10 patients (mean age 68.3) who underwent transurethral prostate resection because of benign prostate hyperplasia (BPH) by immunohistochemistry. Post-mortem prostate samples of three young men (age 18, 28, 33) were used as controls. Tissue samples were embedded in epoxy resin and cut into serial 1 microm sections for colocalization of ABP, OTR, proliferation marker p21 and caveolin 1. ABP was found in stroma of the smooth muscle cells in all studied samples. OTR staining occurred in most of these cells in BPH while controls contained only scattered cells positive for OTR. There were no apparent differences in immunostaining for p21 while immunoreactivity for caveolin 1 was observed in most cells in BPH and only in few cells in controls. Caveolin 1 was mostly colocalized with ABP and OTR in BPH samples while controls did only occasionally show this colocalization. Our observations indicate an interaction of ABP and OTR, associated with caveolin 1, which may account in part for known non-genomic actions of gonadal steroids. Androgen dependent prostate growth in BPH may be linked to these mechanisms.

Changing caveolin-1 and oxytocin receptor distribution in the ageing human prostate.

Several observations suggest that caveolin-1 has an important role in control of cell proliferation and cancerogenesis. For instance, oxytocin provokes a proliferative response in the prostate tissue when the oxytocin receptor is localized mainly in caveolin-1-enriched domains and an anti-proliferative effect when the same receptor is not localized in caveolae. Moreover, oxytocin concentrations are elevated in prostate tissue of patients with benign prostatic hyperplasia (BPH). In this study the expression pattern of the molecules caveolin-1, oxytocin receptor, androgen receptor and p21 (cell cycle arrest indicator) was investigated in the prostate tissue of BPH patients and of young controls. We found that both caveolin-1 and oxytocin receptor expression is drastically increased with age in both smooth muscle and epithelium of the prostate. We also found a significantly increased co-localization of the oxytocin receptor with caveolin-1 in both the muscle and the epithelium, especially in BPH patients. Androgen receptor and p21 staining was found throughout the prostate but did not change significantly with age or in BPH patients. We conclude that oxytocin may have a proliferative effect on the prostate tissue through the caveolae-associated receptors and thus contribute to BPH. This process seems to be androgen receptor independent.

[Sacral nerve root cysts--a rare cause of bladder dysfunction. Case report and review of the literature]. / Sakrale Nervenwurzelzysten--Seltene Ursache von Blasenfunktionsstörungen. Fallbericht und Literaturübersicht.

INTRODUCTION: Asymptomatic cysts of the sacral nerve roots display a prevalence of 5 % and are occasionally demonstrated by MRI of the spine. Depending on their size and localization, arachnoid cysts may cause sacral or perineal pain, radicular sensomotory symptoms and neurogenic bladder and bowel dysfunction by compression of the nerve roots. CASE REPORT: We report on a case of a recently developed neurogenic bladder dysfunction. MRI of the spine demonstrated two large, liquor-filled cysts of 2.5 and 3 cm diameter, bilaterally localized at the nerve roots S2/3. Neurological and urological examinations confirmed the diagnosis of symptomatic nerve root cysts at the level S2/3, resulting in detrusor areflexia. A microsurgical excision of the cysts ameliorated the patient's pain symptoms. However, the detrusor areflexia did not improve. CONCLUSIONS: Tarlov cysts are predominantly regarded an asymptomatic incidental feature of CT and MRI scans of the spine. The case of our patient, as well as the so far published reports indicate, however, that a Tarlov cyst may cause a variety of neurological and urological symptoms. Nerve root cysts should be seriously considered and not excluded at an early stage, especially when coincident with persistent neurological and urological symptoms.

[Surgical techniques in renal transplantation]. / Chirurgisch-technische Aspekte der Nierentransplantation.

Surgical techniques in renal transplantation are standardized and have remained basically unchanged for the last 50 years. A limited pool of donor organs is still an unsolved problem. Therefore, marginal organs are also used. Sophisticated techniques are used in children and in cases with vascular problems or complications. Laparoscopic techniques are emerging in renal transplantation. The article provides an overview on current technical standards of renal transplantation and potential surgical and urological complications. We report the results of our own renal transplantation program with special emphasis on vascular techniques, pediatric transplantation, and the management of complications. Special case reports are included.

Endocrine alteration in the adrenal gland in kidney transplant patients.

INTRODUCTION: Endocrine alterations associated with chronic renal failure have been reviewed recently. Some of these alterations are of clinical relevance. The aim of this study was to investigate the effect of renal transplantation on the endocrine system of the adrenal gland of the transplant recipients. METHODS: The serum angiotensin-converting enzyme (SACE), plasma renin (PR) and plasma aldosterone (PA) were examined in 30 patients before and after renal allotransplantation. Additionally measured parameters were blood pressure, serum creatinine, potassium, sodium, the duration of dialysis and immunosuppressive medication. RESULTS: Six weeks after renal transplantation, serum creatinine decreased from 820.07 +/- 172.01 to 138.12 +/- 67.54 micromol/l. In the same period, serum potassium decreased from 5.42 +/- 0.89 to 4.17 +/- 0.42 mmol/l. PA and PR decreased from 1,150.84 +/- 976.06 to 233.52 +/- 217.07 micromol/l, and from 121.07 +/- 100.12 to 26.16 +/- 10.86 microU/ml, respectively. SACE decreased from 0.21 +/- 0.21 to 0.13 +/- 0.11 micromol/l. No significant correlation was seen with blood pressure, serum sodium, the duration of dialysis and immunosuppressive drugs. Additionally, 2 patients with acute renal graft dysfunction showed significant increases in PR and PA. After successful treatment both levels declined very quickly to prerejection levels. Patients after binephrectomy show no elevation in PR (5-47 microU/ml) or PA (21-416 micromol/l) neither before nor after renal transplantation. CONCLUSIONS: We conclude that renal transplantation has profound effects on the recipient's renin-angiotensin-aldosterone system. Because of the rapid depression after renal transplantation, it does not appear to be involved in the pathogenesis of post transplantation hypertension but may reflect a role for repair processes after renal allotransplantation.

A bridge between neuroscience and oncology: prostate cancer genesis. A 'negative' consequence of learning?

Prostate cancer has become the most commonly diagnosed cancer in men over recent years. The initiating mechanism for tumorigenesis within the prostate remains an unknown. The observation, that the cancer incidence in patients with chronic neurological disabilities is significantly lower than in the normal population lead to the hypothesis, that changed processing due to a barrage of aberrant sensory information within a healthy CNS can trigger events within the prostate cell, that cause malignant transformation. There is a broad overlap of cellular mechanism of gene expression, that lead to either long term potentiation, learning and memory storage or deregulated differentiation and malignant transformation.

The male chronic pelvic pain syndrome.

Suffering chronic pain is a common and debilitating problem that significantly impairs the quality of life of affected patients. Because we continue to struggle with chronic pelvic pain disorders both diagnostically and therapeutically, a neuro-behavioral perspective should be used in an attempt to explain pathways and neurophysiological mechanisms, and to improve diagnostics and treatment of male pelvic pain. First, however, malignant and acute/chronic bacterial disease has to be excluded as a cause of chronic pain in every single case. Then diagnostic approaches should screen for lower urinary tract dysfunction, pelvic floor functional disorders, and disturbed reflex integrity within the pelvic area. Treatment approaches for the male chronic pelvic pain syndrome could be divided into causal and symptomatic. Causal treatment approaches try to influence basic mechanisms generating and supporting chronic pain. In most cases a symptomatic approach is needed to relieve pain immediately. Because generally accepted treatment protocols and studies are missing, the following approach in the individual patient is recommended: (1) symptomatic treatment for immediate pain relief, (2) diagnostic work-up, (3) causal treatment trial.

Chronic perineal pain and lower urinary tract dysfunction--a clinical feature of the "Gulf War syndrome"?

A Persian Gulf War veteran presented to the University Neuro-Urology service for management of severe chronic perineal pain. The overall physical and neurological exam was unremarkable. However, the rectal exam and the urodynamic study revealed a severe pelvic floor dysfunction. A neuro-behavioral approach is recommended and discussed.

Renal cell carcinoma in renal graft recipients and donors: incidence and consequence.

INTRODUCTION AND OBJECTIVES: Numerous studies have reported an increasing incidence of small renal cell carcinoma (RCC). De novo RCC in a renal allograft is a rare event and has special implications in renal transplant recipients. The objective of this study was to retrospectively evaluate the incidence of RCC in renal graft recipients and donors and to determine a procedure in cases with newly detected small renal tumors at the time of kidney preparation before transplantation. MATERIAL AND METHODS: We mailed a questionnaire to 38 German transplant clinics and received answers from 27 centers. A total of 10,997 renal graft recipients were included in the period of 1990-1998. RESULTS: In 30 kidneys (0.273%) RCC was detected at the time of preparation before transplantation. There were 23 male and 3 female donors. No bilateral RCC was described. The mean age of the donors with RCC was 50.9 years (range 37-72 years). The tumors had a mean size of 2.2 cm (range 0.4-6 cm). 67% of the patients had a renal tumor smaller than 20 mm. In 26/27 centers the decision to transplant relies on the result of the immediate section for microscopic examination. 16 patients (0.145%) developed RCC 3-12 years after renal transplantation (mean 7.4 years). The mean tumor size was 2.5 cm (range 2-2.8 cm). In 50% a grade 1 and in the other 50% a grade 2 carcinoma was found. CONCLUSIONS: Because of the RCC incidence in donor candidates we recommend an ultrasound screening of the native kidneys before renal explantation and an immediate preparation of the kidney surface especially in donors older than 45 years. In cases with small renal lesions we recommend an immediate section for microscopic examination before transplantation to prevent tumor implantation into an otherwise healthy patient. The frequency of RCCs after renal transplantation necessitates careful clinical and instrumental examinations in organ-transplanted recipients both before and at regular intervals after transplantation, including the patient's kidneys.