[Urgency after successful treatment of prostate cancer. Prospective study on the influence of treatment modality, morbidity, and epidemiological factors on the quality of life]. / Drangsymptomatik nach onkologisch erfolgreicher Prostatakarzinomtherapie. Prospektive Studie zum Einfluss von Therapiemodalität, Morbidität und epidemiologischen Faktoren auf die Lebensqualität.

BACKGROUND: The aim of this prospective study was to investigate factors influencing long-term health-related quality of life (HRQoL) in patients treated for prostate cancer with no signs of tumor relapse. PATIENTS AND METHODS: We included epidemiological and oncological data as well as standardized questionnaires on incontinence and sexual function. Data were analyzed using standard descriptive and explorative statistics. RESULTS: We obtained pre-therapeutic data as well as a complete data set after 36 months for 488 patients. A total of 162 patients (33.2%) in whom we could not exclude a tumor relapse according to the guidelines of the EAU or because of incomplete data were excluded from further analysis. In a univariate analysis as expected stress incontinence, lower urinary tract symptoms (LUTS), overactive bladder (OAB), urgency, pad use, sexual activity as well as perceived pre-therapeutic HRQoL, being privately insured, and a better school education were significantly associated with post-therapeutic long-term HRQoL (p<0.05). In a multivariate analysis of covariance only dry OAB (p=0.0411) and sexual activity (p=0.0046) proved to be independent parameters with a significant impact on HRQoL after 36 months. CONCLUSION: Symptoms of OAB even without urine loss after successful treatment of prostate cancer need to be addressed in clinical practice as well as in research studies.

Voiding dysfunction due to chronic viral encephalitis in a young woman.

We record a case of a 37-year-old female with acute viral encephalitis, frequency and urgency incontinence. Video urodynamics showed small bladder capacity, sensory urgency, high residual urine and a Christmas tree appearance of the bladder. MRI showed inflammation and edema in the area of the thalamus and internal capsule in the early stage, then cavitation and gliosis in the same regions in the late stage.

[Update of the Clinical Guidelines of the European Association of Urology on muscle-invasive and metastatic bladder carcinoma]. / Actualización de las Guías Clínicas de la Asociación Europea de Urología sobre el carcinoma vesical músculo-invasivo y metastásico.

CONTEXT: New data regarding diagnosis and treatment of muscle-invasive and metastatic bladder cancer (MiM-BC) has emerged and led to an update of the European Association of Urology (EAU) guidelines for MiM-BC. OBJECTIVE: To review the new EAU guidelines for MiM-BC. EVIDENCE ACQUISITION: A comprehensive workup of the literature obtained from Medline, the Cochrane central register of systematic reviews, and reference lists in publications and review articles was developed and screened by a group of urologists, oncologists, and radiologist appointed by the EAU Guideline Committee. Previous recommendations based on the older literature on this subject were taken into account. Levels of evidence and grade of guideline recommendations were added, modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence. EVIDENCE SYNTHESIS: The diagnosis of muscle-invasive bladder cancer (BCa) is made by transurethral resection (TUR) and following histopathologic evaluation. Patients with confirmed muscle-invasive BCa should be staged by computed tomography (CT) scans of the chest, abdomen, and pelvis, if available. Adjuvant chemotherapy is currently only advised within clinical trials. Radical cystectomy (RC) is the treatment of choice for both sexes, and lymph node dissection should be an integral part of cystectomy. An orthotopic bladder substitute should be offered to both male and female patients lacking any contraindications, such as no tumour at the level of urethral dissection. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well-informed, and compliant patients for whom cystectomy is not considered for clinical or personal reasons. An appropriate schedule for disease monitoring should be based on: a) natural timing of recurrence; b) probability of disease recurrence; c) functional deterioration at particular sites; and d) consideration of treatment of a recurrence. In metastatic disease, the first-line treatment for patients fit enough to sustain cisplatin is cisplatin-containing combination chemotherapy. Presently, there is no standard second-line chemotherapy. CONCLUSIONS: These EAU guidelines are a short, comprehensive overview of the updated guidelines of (MiM-BC) as recently published in the EAU guidelines and also available in the National Guideline Clearinghouse.

Chronic subdural hematoma associated with voiding dysfunction.

We report the case of a 73-year-old male who presented with a chronic subdural hematoma that compressed the frontal lobe, an area known to be active in detrusor control, and caused contralateral hemiparesis and urgency incontinence. Urodynamically, he had a small bladder capacity and high amplitude overactive detrusor contractions with an intact sphincteric response. We concluded that the effect of intracranial lesions on voiding depends upon the site rather than the type of the pathology. Further in-depth studies are needed to clarify the effect of intracranial lesions, and accordingly the function of different brain regions and their influence on voiding.

Actualización de las Guías Clínicas de la Asociación Europea de Urología sobre el carcinoma vesical músculo-invasivo y metastásico / Update of the Clinical Guidelines of the European Association of Urology on muscle-invasive and metastatic bladder carcinoma

Contexto: la aparición de nuevos datos relacionados con el diagnóstico y tratamiento de cáncer vesical músculo-invasivo y metastásico (CaV-MiM) ha obligado a una actualización de las Guías sobre el CaV-MiM de la Asociación Europea de Urología (EAU). Objetivo: revisión de las nuevas guías de la EAU para el CAV-MiM. Evidencia adquirida: un grupo de urólogos, oncólogos y radiólogos designados por el Comité de Guías Clínicas de la EAU ha realizado un exhaustivo trabajo de revisión de la literatura procedente de Medline, el registro central Cochrane de revisiones sistemáticas y las citas bibliográficas de publicaciones y artículos de revisión. Se han tenido en cuenta las recomendaciones basadas en la literatura previa disponible sobre este aspecto. Además, han sido añadidos niveles de evidencia y grados de recomendación, según las modificaciones del Oxford Centre for Evidence-based Medicine. Evidencia sintetizada: el diagnóstico de cáncer vesical músculo-invasivo (CaVMI) se realiza mediante la resección transuretral y el consiguiente estudio histopatológico. Una vez confirmada la existencia de CaVMI es preciso realizar el estadiaje mediante tomografía computarizada toraco-abdómino-pélvica, si se dispone de ella. Actualmente, la quimioterapia adyuvante solamente se recomienda en el contexto de ensayos clínicos. La cistectomía radical es el tratamiento de elección en ambos sexos, y la linfadenectomía debe constituir una parte integral de la misma. Tanto a hombres como a mujeres se les debe ofrecer la sustitución vesical ortotópica siempre que no existan contraindicaciones, tales como la existencia de tumor en el margen uretral. En la actualidad, los tratamientos multimodales para la conservación vesical en casos de enfermedad localizada constituyen un alternativa terapéutica solamente en pacientes seleccionados, adecuadamente informados, y en aquellos en los que se desestima la cistectomía por motivos clínicos o personales. Los protocolos de seguimiento deben diseñarse sobre la base de: a) historia natural de la recurrencia; b) probabilidades de recurrencia; c) deterioro funcional en localizaciones específicas; y d) consideraciones sobre el tratamiento de la recurrencia. En la enfermedad metastásica el tratamiento de primera línea para los pacientes con un estado general adecuado para tolerar el cisplatino es la quimioterapia combinada basada en este fármaco. Actualmente no existe una quimioterapia estandarizada de segunda línea. Conclusiones: estas guías de la EAU constituyen un resumen de la exhaustiva visión de conjunto de las guías recientemente actualizadas del CaV-MiM, publicadas en las guías clínicas de la EAU, también disponibles en la National Guideline Clearinghouse(AU)

Context: New data regarding diagnosis and treatment of muscle-invasive and metastatic bladder cancer (MiM-BC) has emerged and led to an update of the European Association of Urology (EAU) guidelines for MiM-BC. Objective: To review the new EAU guidelines for MiM-BC. Evidence acquisition: A comprehensive workup of the literature obtained from Medline, the Cochrane central register of systematic reviews, and reference lists in publications and review articles was developed and screened by a group of urologists, oncologists, and radiologist appointed by the EAU Guideline Committee. Previous recommendations based on the older literature on this subject were taken into account. Levels of evidence and grade of guideline recommendations were added, modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence. Evidence synthesis: The diagnosis of muscle-invasive bladder cancer (BCa) is made by transurethral resection (TUR) and following histopathologic evaluation. Patients with confirmed muscle-invasive BCa should be staged by computed tomography (CT) scans of the chest, abdomen, and pelvis, if available. Adjuvant chemotherapy is currently only advised within clinical trials. Radical cystectomy (RC) is the treatment of choice for both sexes, and lymph node dissection should be an integral part of cystectomy. An orthotopic bladder substitute should be offered to both male and female patients lacking any contraindications, such as no tumour at the level of urethral dissection. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well-informed, and compliant patients for whom cystectomy is not considered for clinical or personal reasons. An appropriate schedule for disease monitoring should be based on: a) natural timing of recurrence; b) probability of disease recurrence; c) functional deterioration at particular sites; and d) consideration of treatment of a recurrence. In metastatic disease, the first-line treatment for patients fit enough to sustain cisplatin is cisplatin-containing combination chemotherapy. Presently, there is no standard second-line chemotherapy. Conclusions: These EAUguidelines are a short, comprehensive overview of the updated guidelines of (MiM-BC) as recently published in the EAU guidelines and also available in the National Guideline Clearinghouse(AU)

[Excision of carcinoma in situ of the glans penis with reconstructive plastic surgery]. / Exzision des Carcinoma in situ der Glans penis mit plastischer Rekonstruktion.

BACKGROUND: Bowen's disease and erythroplasia of Queyrat are intraepidermal neoplasias (carcinoma in situ) and are considered as preinvasive types of penile squamous cell carcinoma. The risk of progression to invasive cancer is low and such a process can last up to 20 years. MATERIAL AND METHOD: Penis preservation and simultaneous complete excision of the tumour are strongly related to the quality of life of the patients and thereby represent the aim of the therapy. Local excision with reconstructive plastic surgery allows satisfactory aesthetic results without jeopardizing cancer control. RESULTS: The results of this treatment are comparable with those after Nd-YAG laser therapy. Local recurrence occurs in up to 33% also after years irrespective of the surgical strategy chosen. CONCLUSION: A close follow-up with timely treatment of recurrences allows suitable tumour control without worsening the prognosis and is the most important requirement for an organ-preserving treatment of Bowen's disease.

[Interdisciplinary recommendations for the treatment of metastatic renal cell carcinoma]. / Interdisziplinäre Empfehlungen zur Behandlung des metastasierten Nierenzellkarzinoms.

With the introduction of targeted therapies, a paradigm shift for the treatment of metastatic renal cell cancer has taken place. New compounds like sunitinib, sorafenib, bevacizumab and temsirolimus have become established as new therapeutic standards. An interdisciplinary consensus conference was held to discuss treatment sequences and open questions. Results from the 2007 conference provided the basis for the 2008 meeting. The results of the 2008 conference are presented as short theses.

[The significance of lymphadenectomy in the management of penile cancer]. / Der Stellenwert der Lymphknotenchirurgie beim Peniskarzinom.

Inguinal lymphadenectomy is performed according to the clinical features as well as the risk factors of the primary tumor. In cases involving more than two positive lymph nodes or extranodal growth as well as positive imaging, pelvic lymphadenectomy is indicated. Large or fixed inguinal nodes as well as iliac lymph nodes seen on computed tomography scanning are a good indication for neoadjuvant rather than adjuvant chemotherapy.

TGFbeta-1 and epithelial-mesenchymal interactions promote smooth muscle gene expression in bone marrow stromal cells: possible application in therapies for urological defects.

PURPOSE: For regenerative and cellular therapies of the urinary tract system, autologous bladder smooth muscle cells (SMCs) have several limitations, including constricted in vitro proliferation capacity and, more importantly, inability to be used in malignant conditions. The use of in vitro (pre-)differentiated multipotential adult progenitor cells may help to overcome the shortcomings associated with primary cells. METHODS: By mimicking environmental conditions of the bladder wall, we investigated in vitro effects of growth factor applications and epithelial-mesenchymal interactions on smooth muscle gene expression and on the morphological appearance of adherent bone marrow stromal cells (BMSCs). RESULTS: Transcription growth factor beta-1 (TGFbeta-1) upregulated the transcription of myogenic gene desmin and smooth muscle actin-gamma2 in cultured BMSCs. Stimulatory effects were significantly increased by coculture with urothelial cells. Prolonged stimulation times and epigenetic modifications further enhanced transcription levels, indicating a dose-response relationship. Immunocytochemical staining of in vitro-differentiated BMSCs revealed expression of myogenic protein alpha-smooth muscle actin and desmin, and changes in morphological appearance from a fusiform convex shape to a laminar flattened shape with filamentous inclusions similar to the appearance of bladder SMCs. In contrast to the TGFbeta-1 action, application of vascular endothelial growth factor (VEGF) did not affect the cells. CONCLUSIONS: The combined application of TGFbeta-1 and epithelial-mesenchymal interactions promoted in vitro outgrowth of cells with a smooth muscle-like phenotype from a selected adherent murine bone marrow-derived cell population.

[Nested-variant urothelial carcinoma. Case report and molecular aspects]. / Die Nested-Variante des Urothelkarzinoms. Fallbericht und molekulare Aspekte.

The nested variant of urothelial carcinoma is a rare urothelial neoplasia which is characterized by relatively bland morphology and early muscle-invasive growth. We report on a 65-year-old male patient with a non-invasive high-grade urothelial lesion (carcinoma in situ and pTa G3). After treatment with BCG an invasive urothelial carcinoma was discovered whereas the carcinoma in situ had disappeared. Examination of the bladder specimen showed a nested-variant urothelial carcinoma. Molecular analyses indicated a de-novo genesis of the invasive urothelial carcinoma.

Urinary sodium dodecyl sulfate electrophoresis with silver staining: a noninvasive diagnostic tool for obstructive uropathy in children.

PURPOSE: Obstructive uropathy such as ureteropelvic junction obstruction in the newborn is a major diagnostic and therapeutic dilemma. We investigated whether urinary sodium dodecyl sulfate electrophoresis with polyacrylamide gel electrophoresis with silver staining could be used to discriminate between children requiring and those not requiring pyeloplasty. MATERIALS AND METHODS: In a pilot study we analyzed the urine of 18 children (mean age 2.7 years) with grade III or IV hydronephrosis according to the Society for Fetal Urology classification. A total of 44 healthy children were studied as controls. Children with hydronephrosis were followed using ultrasound, (99m)technetium mercaptoacetyltriglycine diuretic renography and voiding cystourethrography. Urine was obtained by spontaneous voiding and studied by sodium dodecyl sulfate polyacrylamide gel electrophoresis with silver staining using Melzer's modification. After the study period test results were compared to outcomes, ie whether patients required surgery, and to normalization of previously abnormal protein excretion patterns. RESULTS: All but 1 of the healthy controls had a normal electrophoresis assessment. Of 9 patients followed for hydronephrosis 7 had an abnormal electrophoresis result preoperatively. One child had to be operated on twice because of relapse of ureteropelvic junction obstruction. Six children returned to a normal electrophoresis result postoperatively, including the child who was operated on twice. All children with an initially normal electrophoresis assessment displayed persistent normal values, except 1. Children shifting from a normal to an abnormal electrophoresis result underwent surgery after exclusion of urinary tract infection. CONCLUSIONS: Sodium dodecyl sulfate polyacrylamide gel electrophoresis with silver staining seems to be a good predictive test for clinically relevant ureteropelvic junction obstruction. Further studies are being performed to see whether the test can stand against the gold standard, (99m)technetium mercaptoacetyltriglycine diuretic renography.

[Solitary peritoneal carcinomatosis in prostate cancer]. / Solitäre Peritonealkarzinose eines Prostatakarzinoms.

INTRODUCTION: Peritoneal carcinomatosis is a rare finding in metastatic prostate cancer. In the literature peritoneal carcinomatosis is usually reported in its final stages with multiple metastases. A single peritoneal carcinomatosis with no further metastases is a very rare finding. CASE REPORT: We report the case of a 75-year-old patient with initial ischuria. A prostate cancer could be confirmed and the further diagnostics showed no metastasis. In a transperitoneal approach for laparoscopic pelvic lymphadenectomy a peritoneal carcinomatosis from prostate cancer was proven. A complete antiandrogen therapy was started and PSA decreased for more than 14 months to a stable level of < 1 microg/L. CONCLUSION: An isolated peritoneal carcinomatosis from prostate cancer is a very rare finding. The complete antiandrogen therapy is effective.

[Neoadjuvant and adjuvant chemotherapy in patients with advanced penile cancer]. / Neoadjuvante und adjuvante Chemotherapie bei Patienten mit fortgeschrittenem Peniskarzinom.

With an incidence of 0.1-0.9/100,000 men per year penile cancer is a rare cancer of the urogenital tract in Western Europe. At the time of initial diagnosis up to 45% of the patients already demonstrate metastatic disease and need some type of systemic treatment. It is the aim of this paper to review the current concepts of adjuvant and neoadjuvant chemotherapy for locally advanced penile cancer. A curative effect of combined surgical and cytotoxic management can only be achieved in patients with locoregional spread to the lymph nodes, but not with systemic spread. Although there are prospective randomized trials available indicating the optimal cytotoxic regime, cisplatin-based protocols or combination therapies with bleomycin, vincristine, and methotrexate appear to be the most effective options. Finally, there are no data available with regard to the effect of adjuvant chemotherapy on progression-free survival. In patients with locoregional bulky disease or with fixed inguinal lymph nodes, neoadjuvant chemotherapy will result in a partial response in 20-60% of patients and enables complete resection of the mass. For the future, the use of taxane-based chemotherapy as described for squamous cell cancer of other origin might improve outcome.

[Interdisciplinary recommendations on targeted therapy in the treatment of renal cell carcinoma]. / Interdisziplinäre Therapieempfehlungen zur Behandlung des metastasierten Nierenzellkarzinoms.

Recently, new data have been published on the treatment of metastasized renal cell cancer using targeted therapies. With the approval of the tyrosine kinase inhibitors Sunitinib and Sorafenib, two of these new therapies are now available in clinical practice. This has raised both new opportunities and new questions for the health care professionals involved. Here we report on a consensus conference addressing these questions with answers based on evidence from the recent literature.

[Perineal approach to repair rectal and cutaneous fistulas involving the urethra and bladder]. / Perinealer Zugang zur Korrektur von rektalen und kutanen Fisteln zu Urethra und Blase.

The perineal approach was used in ten patients for the repair of fistulas involving the bladder or prostatic urethra. In the case of radiotherapy-induced (n=2) or recurrent fistulas (n=4) fecal diversion and interposition of the gracilis muscle was performed. In addition in three patients prostatectomy was performed. All fistulas were repaired successfully with minimal morbidity.

[Magnetic stimulation of the pelvic floor in older patients. Results of a prospective analysis]. / Magnetstimulation des Beckenbodens beim älteren Menschen. Ergebnisse einer prospektiven Untersuchung.

Since 2001 magnetic stimulation therapy has been available in Germany for treating urinary incontinence as an alternative to traditional electrical stimulation therapy. The results of 83 patients who underwent magnetic stimulation therapy for stress incontinence, OAB, and pelvic pain syndrome were evaluated. The results differed depending on the underlying disease. Patients with stress incontinence who could not properly contract pelvic floor muscles before could do so in 74% when clinically evaluated and patients with OAB symptoms improved in 54% as assessed by objective and subjective criteria, whereas patients with pelvic pain syndrome only benefited in 23%. Comparison of the results according to age revealed no significant difference between patients >65 years and younger patients.

[Nephron-sparing therapy for renal tumors]. / Die organerhaltende Nierentumor-Therapie.

In this article up-to-date, nephron-sparing therapy for renal cell cancer such as radical tumor nephrectomy, partial resection or enucleation is summarised. The results of open and laparoscopic partial nephrectomy and tumor enucleation are presented. Problems and complications associated with the techniques are reviewed. There are as yet no randomized, controlled trials and most published studies show retrospective data. Further new alternative techniques in nephron-sparing therapy like cryosurgery and radiofrequency ablation are presented.

[Options in palliative therapy for penile cancer]. / Optionen der palliativen Therapie des Peniskarzinoms.

Penile cancer, with an incidence of 0.1-0.9/100,000 males/year, is one of the least common malignant tumors. Most patients are over 50 years old and the tumor is slow growing. Therapeutic success is highly dependent on lymph node status. Cancer related death is usually due to local complications such as arrosion bleeding caused by the tumor or infected inguinal metastases. The therapy for advanced penile cancer and its complications represents a challenge. Taking into consideration quality of life, the therapeutic strategy should be based on the patient's age, his sexual function, motivation and psychological condition, as well as previous illnesses and tumor biology. Palliative therapy requires good interdisciplinary work between oncologists, radiologists, plastic surgeons, physiotherapists and psychologists.

'UroMaix' scaffolds: novel collagen matrices for application in tissue engineering of the urinary tract.

Reconstruction of bladder and ureter tissue is indicated in cases of injury, stenosis, infection or tumor. Substitution by ileum, colon or pure synthetic polymers generates a variety of complications. Biohybrid tissue mimicking structural and functional attributes of the multilayered wall architecture of the urinary conduit may be the solution to current problems. This study reports on porcine urinary tract cells isolated and placed on UroMaix matrices with different degrees of cross-linking produced from highly purified type I collagen from medically approved porcine tissue. A patented procedure revealed membrane structures composed of a dense fibrous side and an open fibrous side. These scaffolds with the porcine urinary tract cells were incubated in a batch culture system for up to 14 days. Cell growth and topographical orientation were examined. Urothelial cells showed maximum attachment and a significant increase of living cells on the dense fiber layer of UroMaix-1. No attachment of urothelial cells occurred on the other prototypes. Smooth muscle cells showed similar behavior within the open fiber layer of all UroMaix matrices. Both urothelial and smooth muscle cells retained their phenotypes as demonstrated by the immunostaining of epithelial cytokeratin 18 and the smooth muscle myosin heavy chain respectively. Thus we could show that UroMaix scaffolds support the attachment and proliferation of urinary tract cells. The elastomeric properties of the collagenous matrices promise attractive applications in the tissue engineering of the urinary tract with its high mechanical demands.