[Focal dose escalation in the treatment of prostate cancer : Long-term results of HDR brachytherapy]. / Fokale Dosiseskalation in der Therapie des Prostatakarzinoms : Langzeitergebnisse der HDR-Brachytherapie.

BACKGROUND: We prospectively examined the effect and the safety of intensity-modulated HDR brachytherapy (IMBT) with focal dose escalation. MATERIALS AND METHODS: A total of 139 patients undergoing primary therapy for prostate cancer and 11 patients with recurrence were included. Data analysis focused on the following factors: date of primary diagnosis, Gleason score, initial prostate-specific antigen (PSA) value, PSA nadir, volume of the prostate in the transrectal ultrasound, biopsy of the prostate gland, androgen deprivation, chemotherapy, uroflowmetry, pre- and postoperative post-void residual urine (PVR), number of the needles in the prostate lobes and analysis of follow-up data. RESULTS: In the primary therapy group, 87.6 % of the patients had a PSA of 0-4 ng/ml at the time of follow-up, while in the recurrence group 81.8 % of patients were within this range. Overall, 55.8 % of patients in the primary group had a PSA nadir under 0.1 ng/ml, 37.2 % under 1 ng/ml, 5.8 % under 5 ng/ml and 1.2 % (1 patient) over 5 ng/ml. In the recurrence group, 100 % had a PSA nadir under 0.1 ng/dl. Fifty patients of the primary group reported grade 1 toxicity (Common Toxicity Criteria): 29 localized to the bladder and 21 to the rectum. Seventeen patients had grade 2 toxicity of the bladder and 1 patient had grade 3 toxicity of the bladder. Finally there was one grade 4 toxicity due to perforation of the sigmoid colon. In the recurrence group, 3 patients with grade 1 toxicity were observed (2 bladder and 1 bowl). Also 3 patients had grade 2 toxicity of the bladder, 1 patient had a grade 3 bladder toxicity and 1 patient had grade 4 toxicity due to bowl fistula. There were no grade 5 toxicities. CONCLUSION: The modifications of the "Kiel method" with focal dose escalation was proven as effective in locally advanced prostate carcinoma and in local recurrences of the disease with low level toxicity.

[Implementation of a scale on stone baskets]. / Implementierung einer Skala auf Steinfangkörben.

BACKGROUND: Complications after endoscopic retrieval of kidney and ureter stones are obviously related to the size of the stones as well as the experience of the surgeon and other factors. During the procedure it is sometimes difficult for surgeons to estimate stone size and therefore give prognostic advises. The visual perception of the stone size depends on the shape, colour, distance to the renoscope and dilatation of the ureter. This is the so-called binding problem, because shape, color and direction of motion are processed separately by different population of optical neurons. In order to establish a better prognostic ratio, especially for less experienced surgeons we established an intraoperative semi-quantitative measurement of the stone size supported by a stone basket. MATERIALS AND METHODS: We modified the tipped nitinol stone baskets from the company Urotech with diameters of 2.5, 3.0 and 4 Ch. The handle of this basket has a spring mechanism, which automatically closes the basket and provides a predefined fixation force of the stones within the basket. On the handle we established a non-linear scale in mm by grabbing standardized balls or standardized screws. RESULTS: The scales are nonlinear because of the nonlinear relation between the diameter of the stone and the distance of the slider. Also the scales differ in between the basket size, because of the different strain conditions due to the different wire sizes and materials or the spring and basket. CONCLUSIONS: This scale could be an important orientation for a surgeon during endourological procedures to estimate stone sizes. It could be used also for the documentation of the size of fragments after an endourologic lithotripsy and could help in the decision for or against an extraction. Finally it could be very interesting for other disciplines like gastroenterology. The scale should be validated in further clinical trials.

[Accidental destruction of stone trapping baskets: new knowledge on the interaction of baskets, stone trapping devices, guide wires and lithotriptors - a brief review]. / Akzidentielle Zerstörung von Steinfangkörben: Neue Erkenntnisse zur Interaktion von Körben, "Stone trapping devices", Guidewire und Lithotriptoren - eine Kurzübersicht.

There is a rise in the incidence of stone disease in the industrial nations. Due to this, the number of endurological procedures will also rise. Sometimes endourological instruments will be fragmented accidentally together with the destruction of the stone. A search for articles on this subject was performed. The aim of this article is to provide a review about the literature on this subject and how this subject can be managed today and in the future.

[The care situation of patients with interstitial cystitis in Germany: results of a survey of 270 patients]. / Die Versorgungssituation von Patienten mit interstitieller Zystitis in Deutschland : Ergebnisse einer Umfrage unter 270 Betroffenen.

BACKGROUND: Using a comprehensive questionnaire the care situation of 270 patients with interstitial cystitis (IC) and bladder pain syndrome in Germany was recorded. Despite comprehensive literature on IC (62,000 citations in PubMed) almost nothing is known of the everyday care and quality of patient care in Germany. RESULTS: In total 94% of the patients were women and 6% men, the average age of women was 53.5 years and that of men 67 years and 47.77% of the patients felt that they were well or very well informed about the disease whereby the internet was the source of information in many cases. The exchange of information among patients will increase further through social networks. The diagnosis of IC was made most frequently (62.22%) by biopsy and histological examination followed by urodynamics, potassium test, hydrodistension and cystoscopy. The average duration of the diagnosis was 9 years, 46.67% of the patients consulted a doctor more than 20 times before the diagnosis was made and 51.84% had to pass water more than 14 times per day. Frequency, nocturia and pain were the leading symptoms and 25% of the patients complained of urge incontinence. Among oral medications, analgesics were taken most frequently (61.7%) followed by pentosan polysulphate, antidepressants, antiepileptic drugs, antispasmodics and remedies for urinary urgency. In the self-assessment of the success of treatment with oral medications (helped very well and well), pentosan polysulphate, analgesics, antidepressants and antiepileptic drugs were considered to be the best. Medications that restore the glucosamine lining of the bladder were used predominantly for instillation into the bladder included hyaluronic acid, chondroitin sulphate and a combination of both and pentosan polysulphate. In the self-assessment of the success of treatment with instillation therapy (helped very well or well) the order was: chondroitin sulphate (62.69%), hyaluronic acid (55.77%), a combination of both (53.66%) and pentosan polysulphate (46.30%). The electromotive drug administration (EMDA) procedure with the use of direct current to introduce medications into the bladder wall was mentioned surprisingly often, namely, in 119 patients. In the self-assessment success (helped very well or well) was considered the best for intravesical procedures with 61.34%. CONCLUSIONS: Compared with all drug procedures instillation of medications into the bladder was mentioned 368 times and was assessed by the patients as having helped very well and noticeably by 53.53%, followed by special invasive procedures at 50.56%/271 mentions, alternative therapies at 41.11%/287 mentions and oral medication at 39.75%/1,024 mentions. Hyaluronic acid and chondroitin sulphate products, the combination of both and pentosan polysulphate (oral and intravesical) are not reimbursed by the statutory health insurance. Over 40% of patients treated with these therefore discontinued the treatment for reasons of cost.

[Recurrent bladder cancer after BCG instillation therapy. Local therapy options?]. / Das Harnblasenkarzinomrezidiv nach BCG-Instillationstherapie. Lokale Therapieoptionen?

Patients with a so-called BCG failure (Bacillus Calmette-Guérin) constitute an inhomogeneous group of patients. Patients with BCG recurrence or BCG refractive tumors are real BCG failures. Therapeutic options are radical cystectomy and a conservative approach, depending on the individual risk of recurrence and progression. Intravesical chemotherapy with docetaxel or gemcitabine after BCG failure shows some promise whereas second line immunotherapy, the combination of BCG and interferon (INF)-α, is an effective regimen but results need to be confirmed. Device-assisted intravesical strategies, such as mitomycin-EMDA or chemohyperthermia are candidates to keep in mind for the near future. Finally, cystectomy results in the best disease-specific survival in patients with BCG failure.

[Non-muscle invasive transitional cell carcinoma of the bladder. New developments in diagnostics and therapy]. / Das nicht muskelinvasive Urothelkarzinom der Harnblase. Neuigkeiten in der Diagnostik und Therapie.

Due to the high incidence and recurrence rate non-muscle invasive bladder cancer (NMIBC) has a relevant impact. Raman spectroscopy and optical coherence tomography represent innovative diagnostic tools. Urine markers still play a minor role in the diagnostics of NMIBC. New therapeutic options are thermochemotherapy and mitomycin-C electromotive drug administration (MMC-EMDA) as well as gemcitabine and apaziquone for intravesical administration.

Laparoscopic versus open bilateral nephrectomy in transplant recipients with medication-resistant hypertension: final results of a multicenter study with 15 years of follow-up.

BACKGROUND: The objective of this study was to evaluate the outcomes of laparoscopic bilateral nephrectomy (LBN) compared with open bilateral nephrectomy (OBN) in transplant recipients with medication-resistant hypertension. MATERIAL AND METHODS: Between 1994 and 2009, 66 renal transplant recipients underwent LBN due to poorly controlled hypertension. We compared them with 44 previous patients who underwent OBN. RESULTS: The mean operative times for LBN and OBN were 195.4 ± 60.1 minutes and 145.7 ± 30.2 minutes, respectively (P = .013). The mean hospital stays were 4.2 ± 2.1 in the LBN versus 10.3 ± 3.9 days in the OBN groups; the mean complication rates were 9.1% versus 18.2%, respectively. At follow-up, the blood pressure (mean value 130/90 mm Hg) in 45 patients (68.2%) among the LBN group was well controlled without the need for antihypertensive medications. In 19 patients (28.8%) significantly fewer antihypertensive drugs (1 or 2) were needed compared with the preoperative status. The remaining 2 patients (3%), both of whom had returned to hemodialysis due to chronic transplant rejection, remained on a combination of 3 or more antihypertensive drugs. Among the open surgery group, 23 subjects (52.3%) showed significantly decreased arterial blood pressure without needing medical therapy; 18 patients (40.9%) required 1 or 2 drugs and the remaining 3 (6.8%) were on a combination of 3 or more antihypertensives. The last cohort had returned to hemodialysis due to chronic transplant rejection. CONCLUSIONS: LBN showed a higher efficacy than open surgery to treat medication-resistant hypertension after renal transplantation, reducing the postoperative trauma and the morbidity rate in high-risk transplant recipients.

[Human placental alkaline phosphatase (hPLAP) is the most frequently elevated serum marker in testicular cancer]. / Die humane plazentare alkalische Phosphatase (hPLAP) ist der am häufigsten erhöhte Serummarker beim Hodentumor.

BACKGROUND: Testicular cancer is the most frequent cancer in patients between 20 and 40 years of age. Cure rates are very high due to standardised operative treatment as well as additional chemotherapy and radiotherapy according to -histological subtype and tumour stage. Histological subtypes are seminoma, non-seminoma and mixed tumours (partly seminoma and partly non-seminoma). The aim of this study was to determine the value of different tumour markers in the primary diagnosis of testicular cancer. MATERIAL AND METHODS: In a retrospective study we investigated 152 consecutive patients with testicular cancer as well as 75 patients with benign scrotal conditions. In all patients the tumour markers human alkaline phosphatase (hPLAP), alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG) and the enzyme lactate dehydrogenase (LDH) were measured. Statistical analyses included descriptive analysis, boxplots, fourfold table, receiver operating characteristic (ROC), calculation of confidence intervals and analysis of variance (ANOVA). RESULTS: 145 patients with a mean age of 34.3 years were eligible. There were 72 seminomas, 33 non-seminomas and 40 mixed tumours with 69% of patients being in Lugano stage I, 19% in stage II and 11% in stage III. hPLAP, AFP and hCG were statistically significantly higher in patients with testicular cancer compared to patients with benign scrotal conditions (p < 0.005). hPLAP showed the best sensitivity/specificity (51.1%/84.0%) followed by AFP (35.7%/97.1%), hCG (32.6%/98.6%) and LDH (31.4%/97.8%). ROC analysis demonstrated no difference between hPLAP, AFP and hCG in the specificity range of 80-100%. However, a combination of hPLAP, AFP and hCG provided statistically significantly better results than single markers (p < 0.001). CONCLUSION: hPLAP is the most often elevated marker in the serum of patients with testicular cancer and potentially demonstrates a significant benefit for therapy monitoring. In our opinion there is a need to debate the consideration of hPLAP in the usual guide-lines of the cancer societies. The unspecific elevation in smokers must be considered. In this regard, reference values of hPLAP depending on smoking habits could be a solution, but valid data are not yet available.

[How accurate is the correlation between clinical and pathological TNM stages in renal tumours?]. / Wie gut ist die Korrelation zwischen klinischen und pathologischen TNM-Stadien bei Nierentumoren?

PURPOSE: In clinical practice the tumour size measured in the histopathological examination of the operative specimen is used both to determine tumour stage. We have investigated the agreement between tumour size determined by preoperative computed tomography (CT) and pathological tumour size. MATERIAL AND METHODS: Between 2000 and 2007 a total of 444 consecutive patients was diagnosed with a renal tumour and treated operatively at our clinic. A total of 276 patients was eligible and thus included in the study. RESULTS: There were 62% men and 38% women with a median age of 65 years. There were 255 renal cell carcinomas, 7 oncocytomas, 3 angiomyolipomas, and 11 tumours of other histology. Mean tumour size was 65 mm in preoperative radiographic estimates and thereby a mean of 3 mm smaller than the mean pathological tumour size (62 mm, p = 0.0000066). In the radiographic estimate only 67% of the tumours were in the range of a 1 cm size difference of the postoperatively determined tumour size and in only 53% of the cases did the clinical and pathological TNM stages match. In 28/276 cases (10%) the clinical tumour stage was ≥ T2 but the histopathological examination showed a pTNM stage < T2. CONCLUSIONS: Different tomographs as well as observers are probably the main causes for the present results. Standardisation should be established to provide an accurate basis for a differentiated discussion about therapeutic options. This is especially true for low tumour stages where tumour size is the only criterion for staging.

[Ureteropelvic junction obstruction with renal hypertension]. / Renaler Hypertonus bei Ureterabgangsenge.

Renal hypertension can occur with unilateral ureteropelvic junction obstruction and consecutive hydronephrosis. It is rarely the main symptom, normally in adults flank pain is in the foreground. We report a case of renal hypertension with ureteropelvic junction obstruction successfully corrected by laparoscopic pyeloplasty and discuss the pathophysiology.

[Non-muscle-invasive transitional cell carcinoma. Is BCG still a necessary part of treatment?]. / Nichtmuskelinvasives Urothelkarzinom. Ist die Anwendung von BCG noch notwendig?

Patients with non-muscle-invasive transitional cell carcinoma are treated in a risk-adopted fashion. Genetically stable low-grade tumors are treated with transurethral resection followed by optional intravesical treatment to prevent tumor recurrence. In cases of high-grade tumors, transurethral resection is followed by a second resection after 4-6 weeks. For patients with carcinoma in situ or high-grade T1 carcinomas, guidelines recommend BCG treatment to prevent recurrence and progression. These recommendations are based on meta-analyses resulting in a 4% reduction of tumor progression. Results published in 2009 and 2010 critically analyze BCG treatment of high-grade bladder tumors and are the focus of this article.

[Endourological lithotripsy for stone removal: accidental fragmentation of dormia basket and guidewire - a brief overview]. / Endourologische Steinlithotripsie : Akzidentielle Zerstörung von Dormiakörbchen und Guidewire - eine Kurzübersicht.

Endoscopic lithotripsy of stones is one of the most frequently performed procedures in urology. Sometimes dormia baskets and guidewire will be fragmented accidentally by the laser (Hol:YAG), by ultrasound, or by mechanical lithotripsy (electromechanical or pneumatic).A search for articles on this subject was performed. The aim of this article is to provide a review about the literature on this subject and how this subject can be managed. In this article we describe the energy needed for destroying specific foreign bodies and what currently and in the future will be the best way to avoid this problem.

Whose transplant function fails after ureteral revision following kidney transplantation?

BACKGROUND: Kidney transplantation is associated with ureteral complications in about 5% of cases. While many reasons for ureteral complications are known, it is currently unknown whether transplant outcomes are affected by operative revision of the transplanted ureter. In a retrospective analysis, we compared patients with versus without loss of transplant function after operative revision for a ureteral complication. PATIENTS AND METHODS: Between 1997 and 2005, a total of 43 ureteral complications occurred in 636 patients (6.8%) after kidney transplantation. Thirty-one of 43 patients underwent open operative revision of the transplant ureter. One patient died from suicide. The remaining 30 patients were analyzed for clinical parameters and transplant outcome. RESULTS: At median 5-year follow-up, 18/30 patients (60%) had functioning transplants and 12/30 (40%) had returned to dialysis. Various parameters such as number of mismatches, ischemia times, number of previous transplantations, and interval from transplantation to occurrence of ureteral complication as well as posttransplant and postrevision serum creatinine values showed no influence on transplant outcomes. CONCLUSIONS: In our retrospective analysis, transplant outcome was not affected by specific parameters associated with operative revision of the transplant ureter.

[Quality of life after radical cystectomy - an overview and analysis of a contemporary series]. / Lebensqualität nach radikaler Zystektomie - Ubersicht und Analyse einer aktuellen Serie.

OBJECTIVE: Published evidence does not support a clear advantage in quality of life for continent versus incontinent urinary diversion or vice versa. PATIENTS AND METHODS: We retrospectively assessed 61 patients after radical cystectomy with the EORTC-QLQ-C30 and -BLM30 instruments. Analysis was performed in dependence of age, sex, technique of urinary diversion and time-course of therapy. RESULTS: 36 patients had an incontinent and 20 patients a continent urinary diversion. Younger patients (p = 0.001) and those with a continent urinary diversion (p = 0.03) were found to have a statistically significant higher incidence of financial problems. Also patients with continent urinary diversion had significantly (p = 0.032) more problems in social integration. Furthermore, there were significant differences in social integration (p = 0.03) and emotional ability (p = 0.008) in the age-dependent analysis. Patients with a continent diversion had significantly more meteoristic problems (p = 0.007). CONCLUSION: This study also could not demonstrate any clear differences in dependence on the technique of urinary diversion. A good postoperative quality of life seems possible independent of age.

[Fluorescence diagnosis in patients with non-muscle invasive bladder cancer: results of a metaanalysis]. / Fluoreszenzdiagnostik bei Patienten mit nicht muskelinvasivem Harnblasenkarzinom: Ergebnisse einer Metaanalyse.

PURPOSE: Heterogeneous results of single studies with photodynamic diagnosis (PDD) in bladder cancer have been reported. A metaanalysis of prospective studies has now been performed. MATERIAL AND METHODS: The effect of PDD in addition to WLC on a) the diagnosis and b) the therapeutic outcome of primary or recurrent non-muscle invasive bladder cancer (NMIBC) investigated by cystoscopy or transurethral resection was analysed. An electronic database search was performed. Trials were included if they prospectively compared WLC with PDD in bladder cancer. Primary endpoints were additional detection rate, residual tumour at second resection and recurrence-free survival. RESULTS: Significantly more tumour-positive patients were detected with PDD in all patients with non-muscle invasive tumours (= 20 %) [95 % confidence interval (CI): 8 to 35 %] and in CIS patients (= 39 %) (CI: 23 to 57 %). Residual tumour was significantly less often found after PDD (odds ratio 0.28, CI: 0.15 to 0.52, p < 0.0001). Recurrence-free survival was significantly higher at 12 and 24 months in the PDD groups than in WLC only groups. CONCLUSIONS: More bladder tumour-positive patients are detected by PDD. Best results were found in CIS patients. Diagnosis with PDD results in a more complete resection and a longer recurrence-free survival.

[Stromal tumour of uncertain malignant potential of the prostate (STUMP) - a case report]. / Stromatumor der Prostata von ungewissem malignem Potenzial (STUMP) - Ein Fallbericht.

A prostatic stromal tumour of uncertain malignant potential (STUMP) is a non-epithelial, mesenchymal spindle-cell tumour that can be classified as a specialised stromal tumour of the prostate. Although in most cases STUMP is not of an aggressive nature, occasional cases have been documented with an extension into adjacent tissues or recurrence after resection. A minority of cases develop a sarcomatous dedifferentiation.We report the case of a 53-year-old male with symptoms of febrile prostatitis. After consolidation we performed TUR-P due to urinary retention. Finally, we made the pathological diagnosis of prostatic STUMP. The patient is being seen -frequently in our clinic to take prostate biopsies to exclude a progression into a stromal sarcoma (active surveillance). After 13 months the STUMP is still detectable, but with no signs of sarcoma.

[Causes and course of fornix rupture]. / Ursachen und Verlauf bei Fornixruptur.

PURPOSE: Fornix rupture is a urological emergency situation. In most cases ureteral stones represent the underlying cause. We present the largest series ever reported. MATERIAL AND METHODS: Between 1994 bis 2005 a total of 162 patients were diagnosed with a fornix rupture. There were 121 men and 41 women with a median age of 53 years (range: 20-79 years). We investigated the following parameters: underlying cause of fornix rupture, symptoms, diagnostic and therapeutic procedures. RESULTS: In 60% of cases a ureteral stone was found as cause and in another 28% we found no reason for fornix rupture. 93% of patients had one or more symptoms at the time of diagnosis. In all patients primary endoscopic therapy (96%) or insertion of a nephrostomy tube was performed (4%). Also, antibiotic treatment was given in 92% of patients. No patient developed a perirenal abscess or other relevant complication requiring open operative revision. CONCLUSIONS: We confirm that ureteral stones are the most frequent causes of fornix rupture. With a low pressure system and antibiotic treatment, secondary complications can be effectively prevented.

[Atypical metastasis of renal cell carcinoma. Contribution of comparative genomic hybridisation to diagnosis]. / Atypische Metastasierung eines Nierenzellkarzinoms. Beitrag der komparativen genomischen Hybridisierung zur Diagnosefindung.

In patients younger than 40 years, renal cell carcinoma and metastases to the bladder are rare. Comparative genomic hybridisation (CGH) may be useful to differentiate between metastatic renal cell carcinoma and secondary malignancies of the genitourinary tract, which can occur in all histologic types. We report the case of a 35-year-old patient with renal cell carcinoma in whom only CGH could help differentiate between a second primary malignancy in the bladder and an atypical bladder metastasis.