Prostate biopsy outcome using 29 mm cutting length.

OBJECTIVES: The aim of the study was to compare the prostate biopsy outcome by using either standard or extended cutting length of the needles. MATERIAL AND METHODS: A total of 74 consecutive prostates from radical prostatectomy were used. Two sextant biopsies were performed ex vivo. We developed a precise simulation of a transrectal biopsy procedure using ultrasound for guiding the needle. In the first set of biopsies an 18-gauge tru cut needle with 19 mm cutting length, powered by a automatic biopsy gun was used. In the second set a single use gun with an 18-gauge end-cutting needle and 29 mm cutting length was used. RESULTS: In the set of sextant biopsies using 19 mm cutting length 49 (66%) carcinomas were found. In the set of sextant biopsies using 29 mm cutting length 58 (78%) of the tumors were detected. 24 (32%) prostates showed tumor in the transition zones, but there was no transition-zone-only cancer in this study. Nevertheless taking longer cores led to an improvement in prostate cancer detection of 18%. CONCLUSIONS: In this ex vivo setting the use of 29 mm cutting length for prostate biopsy led to an significant improvement in cancer detection. As we found the end-cutting needle not suitable for use in the patient, these results support the idea to develop a longer tru cut needle and corresponding gun for further clinical investigations.

One 10-core prostate biopsy is superior to two sets of sextant prostate biopsies.

OBJECTIVES: To compare the efficiency of different transrectal ultrasonography (TRUS)-guided prostate biopsy techniques for detecting prostate cancer. MATERIALS AND METHODS: In all, 81 prostates from radical prostatectomy were used and two consecutive sets of sextant biopsies and one 10-core biopsy taken in each specimen. The 10-core biopsy consisted of a sextant biopsy and four cores from the far lateral areas of the prostate. To simulate a transrectal biopsy procedure, all biopsies were taken under TRUS guidance. RESULTS: In the first set of sextant biopsies 44 prostate cancers (54%) were detected and in the second set 51 (63%). Combining both sets of sextant biopsies 57 (70%) of the carcinomas were detected. One set of 10-core biopsies detected 66 (82%) of all prostate cancers. Overall, with the 10-core biopsies 16% more prostate tumours were diagnosed than with two consecutive sets of sextant biopsies. To find the same number of prostate cancers as with the 10-core technique, 14% of patients undergoing sextant biopsy would require a second set and 11% at least a third set of biopsies. CONCLUSIONS: The 10-core prostate biopsy technique is superior to the commonly used sextant technique and could spare patients unnecessary repeated biopsy. Even after including a second set of sextant biopsies, the total detection rate with these 12 biopsies was inferior to the 10-core technique.

Prostate cancer detection with two sets of ten-core compared with two sets of sextant biopsies.

OBJECTIVES: To compare the cancer detection of two consecutive sets of prostate biopsies using either the sextant or the 10-core technique. METHODS: Ninety-one specimens after radical prostatectomy were used and consecutive sets of biopsies were performed ex vivo on each prostate after the operation. The sextant biopsies were taken paramedian and midlobular, three per side. For the 10-core biopsies, two cores per side from the lateral areas of the prostate were added. We developed a realistic simulation of a transrectal sonographic biopsy procedure. RESULTS: In the first set of sextant biopsies, 55 prostate cancers (60.4%) were found; in the second set, 13 additional tumors were detected. Two consecutive sets of sextant biopsies thus found 68 tumors (74.7%). Using one 10-core biopsy led to cancer detection in 71 of the prostates (78%). A second 10-core biopsy revealed 11 additional tumors, for a cumulative cancer detection rate of 90.1%. We found that 9 (9.9%) of all the cancers were not diagnosed by two consecutive sets of this extended biopsy protocol. Eight of these cancers (88.9%) were clinically significant as determined by a tumor volume larger than 0.5 cm(3). CONCLUSIONS: Although the 10-core protocol is far superior to the commonly used sextant protocol, a significant number of prostate cancers can still be found on a second similar set of prostate biopsies. Even after two consecutive sets of 10-core biopsies, approximately 10% of the prostate tumors remained undetected. Most of them were clinically significant.

[Urethrovaginal fistula in Behçet disease]. / Urethrovaginale Fistel bei Morbus Behçet.

Besides other organ manifestations, the urinary tract can also be affected in the case of Behçet's syndrome. To our knowledge, the formation of fistulae in the urinary tract has not previously been described in this condition. Our report describes a patient suffering from urethro-vaginal fistula and Behçet's syndrome. Operative correction was carried out with vaginal access according to Martius' procedure.

[Endoscopic removal of a fibroepithelial ureteral polyp]. / Endoskopische Entfernung eines fibroepithelialen Harnleiterpolypen.

Fibroepithelial polyps are rare benign ureteral neoplasms of mesodermal origin, found mostly in the proximal ureter. Precisely in these cases, ureteroscopy is extremely important in diagnosis and therapy. We report on a case of a distal fibroepithelial polyp that was removed endoscopically. The base of the tumour was coagulated by laser.

[Surgical techniques in prostate cancer]. / Operative Techniken beim Prostatakarzinom.

Diagnostic, therapeutic and palliative procedures in carcinoma of the prostate are discussed. Staging lymphadenectomy of pelvic lymph nodes has recently been performed via the laparoscope. Our results achieved with this procedure in, to date, 25 patients revealed lymph nodes metastasis in 50% of the cases, although the CT scan was unremarkable. Radical prostatovesiculectomy is accepted as the method of choice for the curative treatment of non-metastatic carcinoma of the prostate. Life expectancy following radical prostatectomy in tumor stage 2 or below, is similar to the general population of the same age. The palliative procedure of choice in prostatic carcinoma is plastic orchiectomy, in which the androgen-producing gonadal tissue is removed and testicular coat, together with the epididymi left in situ. With this approach, partial remission, rarely even complete remission, can be achieved in 80% of the patients. Information in the literature on prolongation of survival as a result of androgen deprivation is, however, contradictory.

[Treatment of distal urethral cancer by laser coagulation]. / Behandlung des distalen Urethrakarzinoms durch Laserkoagulation.

Primary carcinoma of the urethra is a rare lesion, and there are no standard therapeutical modalities suggested in the literature. We report the case of a 65-year-old woman with transitional cell carcinoma of the distal urethra and metastasis to the inguinal lymph nodes (T2 N1 MO G2). Locally, the lesion was treated by Nd:YAG laser coagulation in four sessions. Ileoinguinal and pelvic lymph-node dissection was performed as a diagnostic and therapeutic procedure. Twenty-eight months after the initial treatment, no evidence of tumor recurrence has been found, although extensive biopsy specimens have been taken. Clinical staging showed no evidence of metastases.

[Intracorporeal shockwave lithotripsy using the neodymium YAG laser]. / Intrakorporale Stosswellenlithotripsie mit dem Neodym-YAG-Laser.

The problem of suitable energy transfer and conversion for intraureteral lithotripsy has not yet been solved satisfactorily. Laser-induced shockwave lithotripsy (LISL) appears to be a very promising solution to this problem. We report on initial clinical experience using a Q-switched Nd:YAG laser generating a shockwave on the metallic surface of an optomechanic coupler. This leads to the fine fragmentation of a urinary calculus situated close to or in contact with the coupler. Only minimal side effects occur in biological tissue. Further development of the coupler resulted in considerable increase of its fragmentation capability with no increase in side-effects. As a result, application under fluoroscopic control alone became possible, which appears adequate in approximately half of the cases. In the other half visual inspection via ureteroscopy is required. Laser-induced lithotripsy is the only technique that uses a flexible transmission system, results in the fine fragmentation of calculi, and is free of serious side effects on tissue, i.e. does not lead to perforation of the wall of the ureter.

Laser treatment of ureteral tumors.

Ureteroscopic laser coagulation was performed in 20 patients. In 4 of these patients endoscopic treatment was judged to be incomplete and biopsy demonstrated a muscle invasive tumor in 3 and a poorly differentiated tumor in 1. Therefore, segmental resection or nephroureterectomy followed. In the other 16 patients laser treatment alone (8) or in conjunction with electroresection (8) eradicated the tumor successfully. All of these were stage Ta or T1 and grade 1 or 2 tumors. Three recurrences (after 12, 24 and 49 months) were detected within a medium observation period of 13.8 months and could be eradicated easily with the laser, since these tumors were small. A ureteral stricture developed at the treatment site once in the "laser only" group and 3 times in the group with laser treatment and electroresection. Endoscopic laser coagulation seems to be a promising treatment modality for selected small ureteral tumors. Electroresection has a high risk for development of a ureteral stricture. Regular retrograde ureteropyelography is mandatory for follow-up.

[Extra-corporal shock wave lithotripsy using the HM3 Dornier lithotripter with a modified shock wave generator. Initial clinical reports of experiences]. / Die ESWL mit dem Dornier-Lithotripter HM 3 mit modifiziertem Stosswellengenerator. Erste klinische Erfahrungsberichte.

We report on the clinical application of a modified shock-wave generator for the Dornier Lithotripter HM 3. Stone fragmentation, complication rate, and frequency of auxiliary measures were unchanged in comparison to the former generator. The new shock-wave generator led to markedly reduced patient discomfort during treatment, with the result that more than 50% of all ESWLs could be done with sedation only or without any medication.

Cytologic regression grading of hormone-treated prostatic cancer.

Aspiration cytology during hormone treatment of prostatic cancer has been regularly performed at the University of Munich for 13 years and gives direct information on the primary tumor. To analyse its value in clinical practice, 919 biopsies of 187 patients were reviewed without knowledge of clinical data and the charts were analysed retrospectively. Each biopsy was classified as having good, medium, or poor therapeutic response depending on the regressive changes of the cells. Agreement between two independent observers was 89%. All but 39 of these patients have died and the surviving patients have a minimum observation period of 5.6 years. A poor therapeutic response was seen cytologically in 72 patients (38.5%) at variable times after treatment began. These patients have a statistically significant worse survival in comparison to all other patients. Forty-seven of these 72 patients had deterioration, but clinical signs developed later in 23 cases (mean 1.1 years); in 21 patients cytology and clinical signs were simultaneous and in only three cases clinical deterioration preceded aspiration cytology (mean 4.8 months). In 25 cases there was a cytologically poor therapeutic response, but no clinical signs of deterioration. These patients had the same survival rate as with good or medium treatment response. Serial aspiration cytology is a very valuable parameter in treatment monitoring and is often the early warning sign of endocrine treatment failure.

Fine-needle antegrade pyelography of transplanted kidneys.

Ureteral obstruction or perforation must be considered as a cause of poorly functioning renal transplants. Sonography and radionuclide scanning will demonstrate outflow obstruction and/or pararenal fluid collection, but do not usually provide sufficient information on the site of the lesion. In these cases we have successfully used fine-needle puncture of the renal pelvis under sonographic guidance, and antegrade pyelography. This technique shows excellent anatomical details of the renal pelvis and ureter.

[Aminoglutethimide in the treatment of advanced prostatic cancer]. / Aminoglutethimid zur Behandlung des fortgeschrittenen Prostatakarzinoms.

A total of ten previously castrated men with stage D carcinoma received 1000 mg aminoglutethimide and 50 mg/die cortisoneacetate. The patients were evaluated using the criteria of the National Prostate Cancer Project. No patients showed objective response, three patients had reduction of bone pain and subjective improvement. Pretreatment testosterone, prolactine and estradiol levels were measured. Three patients had a statistically significant elevation of testosterone levels.

[Percutaneous nephrolithotomy and litholapaxy. Endoscopic destruction and removal of kidney calculi]. / Perkutane Nephrolithotomie und Litholapaxie. Endoskopische Zertrümmerung und Entfernung von Nierensteinen.

With the development of the ultrasonically guided punction of the kidney it has become possible nowadays to achieve direct access to the kidney without much difficulty. The puncture tract can be widened and used for the entrance of the so-called nephroscope, which enables the sitting and extraction of renal calculi, which are not able to drain away by themselves. The calculi are removed through the shaft by small forceps. Larger calculi are chiefly removed by means of ultrasonic probes or electro-hydraulic shock waves. This method of percutaneous lithotripsy or litholapaxy is also suitable for the extraction of calculi from kidneys with impaired drainage. Since the procedure can be carried out in a large proportion of patients with local anaesthesia, there are hardly any contraindications--except in cases of complete staghorn calculi. In contrast to the extracorporeal shock wave lithotripsy little apparatus is needed and it is not too expensive; therefore, it is also suitable for smaller hospitals and departments. The percutaneous lithotripsy represents a safe method of renal calculus extraction with little stress for the patients.

[Non-operative treatment of ureteral calculi using ureterorenoscopy]. / Nicht-operative Behandlung von Harnleitersteinen mit Hilfe der Ureterorenoskopie.

Rigid transurethral ureteroscopy was used in the treatment of 31 patients with 32 ureteral calculi. The stones could be visualized in 90% of cases. The aim of treatment was immediate extraction under visual control for smaller calculi and retrograde advancement into the renal pelvis with subsequent extracorporeal shock wave lithotripsy for larger calculi. The aim of treatment was reached in 92% (11/12) of stones in the lower third of the ureter, in 67% (4/6) in the middle third and in 64% (9/14) in the upper third of the ureter leaving 12 calculi extracted and 12 pushed up into the renal pelvis. Electrohydraulic lithotripsy in the ureter was used in 3 cases before extraction. Ureterolithotomy had to be carried out in 3 patients only (9%) following the endoscopic procedure.

[Crossed dystopia of the kidney and an ectopic ureteral orifice]. / Gekreuzte Dystopie der Niere und ektope Harnleitermündung.

We report on a case of crossed renal ectopia with fusion and a refluxing single ectopic ureteral orifice in the prostatic urethra in a renal transplant recipient. The diagnosis was made on the basis of a chronic urinary tract infection and a refluxing ectopic ureteral stump. Crossed ectopia with fusion was found intraoperatively. Nephroureterectomy cured the urinary tract infection.