Long-term experience of hyperbaric oxygen therapy for refractory radio- or chemotherapy-induced haemorrhagic cystitis.

BACKGROUND: Radiotherapy and cyclophosphamide-induced haemorrhagic cystitis are rare but severe complications occurring in 3-6% of patients. Hyperbaric oxygen treatment (HBOT) has been demonstrated to be an effective treatment for haematuria not responding to conventional management. Only very few data exist for long-term follow-up after HBOT. METHODS: We retrospectively reviewed 15 patients referred for HBOT for haemorrhagic cystitis (HC). HBOT was performed for 130 min/day at a pressure of 2.4 atmospheres. We evaluated patient demographics, type of radio- and chemotherapy and characteristics of haematuria. The effect of HBOT was defined as complete or partial resolution of hematuria according to the RTOG/EORTC grade and Gray score. RESULTS: A total of 15 patients (12 after radiotherapy, two after chemotherapy and one patient with a combination of both) were treated with a median of 34 HBO treatments. Radiotherapy patients received primary, adjuvant, salvage and HDR radiotherapy (60 - 78 Gy) for prostate, colon or cervical cancer. The patient with combination therapy and both of the chemotherapy patients were treated with cyclophosphamide. First episodes of haematuria occurred at a median of 48 months after completion of initial therapy. The first HBOT was performed at a median of 11 months after the first episode of hematuria. After a median of a 68-month follow-up after HBOT, 80% experienced a complete resolution and two patients suffered a singular new minor haematuria (p < 0.00001). A salvage-cystectomy was necessary in one patient. No adverse effects were documented. CONCLUSIONS: Our experience indicate that HBOT is a safe and effective therapeutic option for treatment-resistant radiogenic and chemotherapy-induced haemorrhagic cystitis. For a better evaluation prospective clinical trials are required.

Second transurethral resection after Ta high-grade bladder tumor: a 4.5-year period at a single university center.

PURPOSE: We evaluated the results of second transurethral resections of the bladder (TURB) after pTa high-grade bladder cancer over a 4.5-year period. PATIENTS AND METHODS: From July 2007 to December 2011, 2,159 TURBs were performed at our institution, of which 1,143 were initial resections for primary bladder tumor or recurrence. Of these, 142 revealed pTa high-grade bladder cancer, and here we investigated tumor characteristics of initial TURB and results of second resection. RESULTS: The incidence of pTa high-grade tumor was 12.4% (n = 142). Of 87 patients who underwent a second resection, tumor was found in 36 (41.4%); tumors were multifocal in 25 (69.4%) and <3 cm in 29 (80.6%). Tumor was detected at the primary site in 38.9%, at other locations in 22.2%, and at both in 38.9%. Histology revealed pTa low-grade in 13 (14.9% of 87), pTa high-grade in 15 (17.2%), and pT1 in 5 (5.7%) patients. No muscle-invasive tumor was detected. A significant association was found for the number of tumors at initial TURB: in patients with tumor at second resection, 55.1% had had multiple tumors at first resection, more than twice those with solitary tumor (23.7%) (0.004). CONCLUSIONS: In our study, Ta high-grade tumors show a relevant rate of persistent tumor at second resection, most of them located at the primary tumor site. As recommended by the American and European clinical guidelines, patients with Ta high-grade tumor should undergo second resection.

Novel options for the treatment of castration-resistant prostate cancer.

Docetaxel had been the only treatment of castration-resistant prostate cancer (CRPC) that demonstrated a survival benefit for the patients. After its approval, no considerable progress has been made for several years until cabazitaxel and abiraterone acetate demonstrated a significant survival benefit in phase III clinical trials. Apart from that several other new drugs appeared including inhibitors of the androgen receptor (MDV3100), endothelin receptor antagonists (atrasentan, zibotentan), bone-targeted drugs (denosumab, Alpharadin) and immunotherapies (sipuleucel-T) capable of improving the prognosis of patients with CRPC. Here, we review the most recent advances in the treatment of CRPC and highlight the most promising new agents currently being investigated in clinical trials.

Long-term treatment of erectile dysfunction with a phosphodiesterase-5 inhibitor and dose optimization based on nocturnal penile tumescence.

OBJECTIVE: To test the hypothesis that a variable dosage of the oral phosphodiesterase type 5 (PDE5) inhibitor sildenafil (25, 50, 100 mg) or vardenafil (5, 10, 25 mg) determined according to results obtained from nocturnal penile tumescence and rigidity (NPTR, RigiScan), given nightly for 1 year, can improve spontaneous erectile function (EF) in men with mild-to-moderate arteriogenic erectile dysfunction (ED); this regimen was compared with a fixed daily dosage of sildenafil 25 mg or vardenafil 5 mg. PATIENTS AND METHODS: In a prospective open-label, parallel-group trial 154 men with ED were randomized either to fixed low-dose sildenafil 25 mg or vardenafil 5 mg (group 1) or to the lowest erectile dosage of sildenafil (25, 50 or 100 mg) or vardenafil (5, 10 or 20 mg) (group 2) provoking an erectile event as measured by NPTR nightly for 1 year. The EF domain of the International Index of Erectile Function (IIEF) was assessed before and 1 year after the beginning of treatment, and at 4 weeks after ending treatment. RESULTS: After 1 year, 27 of 63 (64%) evaluable men in group 1 had an EF domain score in the normal range, vs 46 of 61 (75%) men in group 2. After the subsequent 4-week wash-out phase, both groups continued to have improved EF domain scores; 22 of 63 (35%) men in group 1 still had a score in the normal range, whereas 38 of 61 (62%) in group 2 had a normal score. The EF domain score in group 1 and 2 improved significantly after 1 year of treatment, from 13.6 to 18.9, and 15.1 to 23.9, respectively (P < 0.01). After the subsequent 4-week wash-out phase, men from both groups maintained this significant level of EF, at 17.1 and 22.4, respectively (P < 0.05). CONCLUSION: Nightly PDE5-inhibitor treatment 1 year in a dosage determined by NPTR measurements results in better EF than giving a fixed dosage of sildenafil (25 mg) or vardenafil (5 mg). This improvement persisted for >4 weeks beyond the end of treatment. The results from this open-label, randomized trial warrant verification under double-blind, placebo-controlled conditions.

Hematospermia-a Symptom With Many Possible Causes.

BACKGROUND: Hematospermia, or blood in the ejaculate, is a symptom with many possible causes that often gives rise to worry. Precise figures on its prevalence are unavailable. It is most common in men under 40, and its cause is usually benign; nonetheless, even a single episode of hematospermia calls for a basic diagnostic evaluation. METHODS: This review is based on pertinent articles re trieved by a search in PubMed with the key words "hemato spermia," "hemospermia," "ejaculation," "male semen," and "transrectal ultrasound." RESULTS: A diagnostic algorithm for hematospermia is described. The most common cause is iatrogenic trauma, in particular transrectal ultrasound-guided prostate biopsy to rule out prostate cancer. Urogenital infections are the second most common cause. Pathological changes of the prostate should be considered along with systemic causes, e.g., arterial hypertension or various hematologic disorders. A single event in men under 40 should be evaluated by precise history-taking, a meticulous physical examination including blood-pressure measurement, and urinalysis. Repeated episodes, or hematospermia in men over 40, calls for additional evaluation with further laboratory tests, imaging studies, and, in some cases, interventional diagnostic procedures. CONCLUSION: Further tests, preferably imaging studies, seem a reasonable way to detect or exclude potential causes of hematospermia, especially malignant ones. The treatment is directed at the underlying cause.

Patients with localised prostate cancer (t1 - t2) show improved overall long-term survival compared to the normal population.

BACKGROUND: Little information is available on the long-term outcomes of patients with localised prostate cancer. OBJECTIVE: To examine the long-term survival of patients with localised prostate gland carcinoma T1 - T2, N0, M0 (UICC stage I and II) compared to the normal population. DESIGN: Retrospective cohort. SETTING: Regensburg, Germany. PARTICIPANTS: Data on 2121 patients with histologically-confirmed, localised prostate cancer diagnosed between 1998 and 2007 were extracted from the cancer registry of the tumour centre in Regensburg, Germany. MEASUREMENTS: Overall survival rate in the patient cohort was estimated and compared to the expected survival rate of a comparable group in the general population derived from the official life-tables of Germany stratified by age, sex and calendar year. RESULTS: Ten years after diagnosis, patients with stage I and II localised prostate gland carcinoma had an approximately 10% increase in survival compared to the normal male population (Relative Survival = 110.7%, 95%-CI 106.6 - 114.8%). LIMITATIONS: We did not examine the effect of cancer treatment or cancer aggressiveness on the overall survival of patients. We did not assess the incidence of subsequent non-primary cancers in our patient population or how this incidence affects the patients' follow-up care and survival. CONCLUSIONS: Patients with stage I+II localised prostate gland carcinoma have improved survival compared with the normal male population. This finding cannot be explained solely by the administration of prostate carcinoma treatments, suggesting that men who participate in PSA screening may have better overall health behaviors and care than men who do not participate in screening. Future research should examine how treatment choice, especially an "active surveillance" approach to care, affects survival in these patients more than ten years after diagnosis.

The undescended testis: diagnosis, treatment and long-term consequences.

BACKGROUND: The late descent of a testicle into the scrotum may impair its development. Reduced fertility is the main risk of primary cryptorchidism even after timely treatment, as histopathological changes (Leydig cell hypoplasia) already become apparent in the first few months of life. There is evidence, however, that treatment is often delayed. Hormonal and surgical treatments complement each other and should be provided before the child's first birthday. METHODS: Selective literature search in PubMed (January 2008) based on the following keywords: "cryptorchidism", "maldescensus testis", "etiology", "therapy", "semen quality", "testicular cancer". Particular attention was paid to the current S2 guidelines on cryptorchidism. RESULTS/DISCUSSION: Hormone therapy is the best initial treatment in most cases, with a few exceptions. If this is unsuccessful, surgery should be performed without delay. The success of treatment depends on the initial position of the testicle. Treatment does not lessen the risk of malignancy. Parents must be informed about this risk. The undescended testicle is the most common genital malformation in boys. When diagnosed, it should be treated hormonally and/or surgically before the child's first birthday to minimize the risk of impaired fertility. Successful treatment before age 13 appears not to lessen the risk of testicular cancer, but it does facilitate early detection by enabling physical examination of the testicle.