Clinical nodal staging scores for prostate cancer: a proposal for preoperative risk assessment.

BACKGROUND: Pelvic lymph node dissection in patients undergoing radical prostatectomy for clinically localised prostate cancer is not without morbidity and its therapeutical benefit is still a matter of debate. The objective of this study was to develop a model that allows preoperative determination of the minimum number of lymph nodes needed to be removed at radical prostatectomy to ensure true nodal status. METHODS: We analysed data from 4770 patients treated with radical prostatectomy and pelvic lymph node dissection between 2000 and 2011 from eight academic centres. For external validation of our model, we used data from a cohort of 3595 patients who underwent an anatomically defined extended pelvic lymph node dissection. We estimated the sensitivity of pathological nodal staging using a beta-binomial model and developed a novel clinical (preoperative) nodal staging score (cNSS), which represents the probability that a patient has lymph node metastasis as a function of the number of examined nodes. RESULTS: In the development and validation cohorts, the probability of missing a positive lymph node decreases with increase in the number of nodes examined. A 90% cNSS can be achieved in the development and validation cohorts by examining 1-6 nodes in cT1 and 6-8 nodes in cT2 tumours. With 11 nodes examined, patients in the development and validation cohorts achieved a cNSS of 90% and 80% with cT3 tumours, respectively. CONCLUSIONS: Pelvic lymph node dissection is the only reliable technique to ensure accurate nodal staging in patients treated with radical prostatectomy for clinically localised prostate cancer. The minimum number of examined lymph nodes needed for accurate nodal staging may be predictable, being strongly dependent on prostate cancer characteristics at diagnosis.

Isolated glans insufficiency due to venous leakage.

Lack of tumescence of the glans penis during normal penile erection may represent a handicap to sexual intercourse. The pharmacodynamic spongiosography for the evaluation of venous drainage of the corpus spongiosum is described, demonstrating a pathologic venous outflow. The patient was successfully treated by resection and ligature of the deep dorsal vein. This procedure is simple to perform and could constitute a therapy for this clinical pathologic entity.

[Pulsed duplex sonographic follow-up of varicoceles following sclerotherapy]. / Gepulste duplexsonographische Verlaufskontrollen der Varikozele nach Sklerotherapie.

Forty-one patients were examined by pulsed duplex sonography immediately before and then one, four and twelve weeks following sclerotherapy of a varicocele. The severity of the varicocele was determined by sonography before treatment and confirmed by phlebography. Sonographic follow-up showed reduction, or disappearance, of the varicocele in 78% of cases. Doppler examination confirmed successful treatment in 85% of patients. Pulsed duplex sonography, combining a non-invasive imaging method and a functional technique, is well suited for the follow-up of varicoceles after treatment.

[Disorders of erectile potency in diabetes mellitus]. / Erektile Potenzstörung bei Diabetes mellitus.

The incidence of erectile dysfunction in patients with long-term diabetes mellitus can be as high as 50%. Diabetic microangiopathy is regarded as the most important pathogenic factor. In this review of a group of 210 impotent patients evaluated and treated at our centre we report on the examination data (angiopathy, neuropathy, psychogenic factors) in 36 patients with diabetes in comparison with the corresponding findings in 169 non-diabetic patients. In 5 patients erectile dysfunction had actually preceded the clinical manifestations of diabetes mellitus. Autoinjection therapy was started in 62% of all the diabetic patients, since this is effective, minimally invasive and, therefore, applicable to a large group of patients. This form of therapy was accepted by 90% of our patients' partners, which is in accordance to the reports in the literature. However, treatment had to be interrupted in 2 out of the 22 patients, owing to lack of cooperation on the part of the sexual partner. No complications were attributable to autoinjection therapy.

[Erythrocyte morphology in asymptomatic microhematuria: experimental studies and clinical significance]. / Die Erythrozytenmorphologie bei asymptomatischer Mikrohämaturie: Experimentelle Untersuchungen und klinische Bedeutung.

Renal and postrenal origin of hematuria can be differentiated by analysis of the morphology of the erythrocytes in the urinary sediment. In order to investigate the mechanisms which cause the membrane changes in dysmorphic erythrocytes, indicating renal origin of bleeding, normal red blood cells were exposed in vitro to an osmotic environment similar to that of the nephron. Upon exposure of osmotically challenged erythrocytes to a hemolytic environment, 50 to 90% of the cells became dysmorphic in a time- and dose-dependent manner and were indistinguishable on light and electron microscopy from those obtained in vivo from a patient with proven glomerular microhematuria. The reliability of erythrocyte morphology in differentiating between renal and postrenal microhematuria was evaluated by performing microscopic analysis as the initial step in the investigation of 316 consecutive patients. In 123 patients with eumorphic red cells in their urine complete urological investigation revealed a postrenal source of bleeding in 85%. Out of 193 patients with dysmorphic erythrocytes, 132 were followed up for at least 2 years after only minimal diagnostic evaluation. An additional postrenal source of bleeding developed in two patients, which was easily diagnosed by the change in erythrocyte morphology. Our studies, representing experience over 6 years with asymptomatic microhematuria, show that microscopic examination of erythrocyte morphology as initial diagnostic step is a safe, inexpensive and efficient method which renders invasive investigations superfluous in the majority of patients.

[Methods of diagnosis and treatment of idiopathic varicocele in Germany, Austria and Switzerland (author's transl)]. / Methoden der Diagnostik und Therapie bei idiopathischer Varikozele im deutschsprachigen Raum.

Replies from 115 urological departments, which were part of a general inquiry within Germany, Austria and Switzerland, were evaluated. 37% of all departments perform a varicocelectomy already after the 6th year of age, 68% after 10 years of age. A preoperative phlebography is performed regularly only by 8%, but the phlebography prior to recurrent surgery is carried out by 72%. The most frequent operative method is the Bernardi technique in 39%, the method of Palomo, ligation superior to the internal inguinal ring and lumbal ligation of the spermatic vein are used equally often. The additional dissection of accompanying veins at the level of internal inguinal ring was reported only by 24%. A postoperative inspection with palpation control is regularly performed by 85%, with semen analysis in 58%. No department reported, postoperative results with sperm analysis for more than one year.

[Persistent microhematuria: localization of the source of bleeding by the evaluation of erythrocyte morphology]. / Persistierende Mikrohämaturie: Lokalisation der Blutungsquelle durch Beurteilung der Erythrozytenmorphologie.

Evaluation of erythrocyte morphology enables differentiation between renal-parenchymatous and postrenal microhematuria. In case of renal erythrocyturia, further examination is carried out with a nephrologist following abridged urologic examination. If the erythrocytes in the urinary sediment are established as being unchanged (postrenal cause of bleeding), a complete urological check is carried out. Today, renal-parenchymatous erythrocyturia can be established with great certainty without a kidney biopsy.

[Blood loss and absorption in TURP vs. TUVRP under low pressure and high pressure conditions]. / Blutverlust und Einschwemmung bei TURP vs. TUVRP unter Niederdruck- bzw. Hochdruckbedingungen.

This study analyzes the causes of different fluid absorption and loss of blood in TURP (transurethral resection of the prostate) and also compares TURP with TUVRP (transurethral vaporesection of the prostate). Continuous intraoperative, intravesical pressure measurement and registration of the extent of fluid absorption (measurement of C(2)H(5)OH in the patient's expiratory air) and precise intra- and postoperative analysis of serum and ASTRUP analysis made it possible to differentiate between high- and low-pressure TUR. In addition positive and negative characteristics of TUVRP could be examined. When fluid absorption was registered, a clear correlation between C(2)H(5)OH absorption and decrease in serum concentration of sodium could be seen, making sodium in serum a good marker of fluid absorption. Neither the duration of the operation nor the size of the adenoma had an influence on fluid absorption and loss of blood, but sinus bleeding and capsular lesions, especially in high-pressure TUR, had a significant influence. An advantage of low-pressure TUR, especially in "low compliance bladder," could be clearly seen. No benefit concerning fluid absorption and loss of blood was seen in cases of total resection by TUVRP. In cases of palliative, planned TUR (elderly patients with multiple risk factors) a TUVRP is recommended.

Is penile atherosclerosis the link between erectile dysfunction and cardiovascular risk? An autopsy study.

Erectile dysfunction (ED) is increasingly linked to coronary heart disease risk. Aim of this study was to test the hypothesis whether this association is due to penile atherosclerosis. We evaluated the prevalence and severity of penile atherosclerosis in relation to coronary and peripheral atherosclerosis. Between January and June 2010, a consecutive series of 31 men underwent an autopsy at the Department of Pathology at the Medical University Vienna. Atherosclerosis at the following localizations were histologically classified: right coronary artery, left coronary artery, left circumflex artery, internal iliac artery, dorsal penile artery and deep penile artery (bilateral). Coronary and peripheral atherosclerosis was present in 87.1 and 77.4% of cases. Atherosclerosis of penile arteries was detectable in only 4 men (12.9%). The only factor linked to penile atherosclerosis was diabetes (P=0.03). All other parameters as assessed according to medical history, general finding from autopsy or histological results regarding arterial lesions in general were not correlated to penile arterial lesions. In contrast to the high prevalence of atherosclerosis in general, penile arterial lesions are rarely present.

[Erectile dysfunction]. / Die erektile Dysfunktion.

Diagnostics and therapy of erectile dysfunction are currently one of the main issues dealt with by urologists. The Androcheck--the recommended annual medical checkup for men above 50 years of age--has taken this fact into account. Nearly 10% of all men suffer from persistent erectile malfunction. In addition to age, typical risk factors are diabetes, hypertonia, chronic nicotine abuse, other chronic illnesses as well as operations in the pelvis. Modern diagnostics work in three steps and take into consideration from the beginning the therapeutical requests by both the patient and his partner. The more invasive the therapy, the more extensive as well as comprehensive the preliminary diagnostics must be. After the obligatory basic examination, a Sildenafiltest may already present a satisfactory solution for therapy. With the introduction of this first potent oral drug for the therapy of erectile dysfunction, the status of all other therapy options has changed as a consequence. The indication for semi-invasive therapies such as intraurethral applications of prostaglandin E 1 or invasive methods such as the auto-injection therapy have become far more rare. On the other hand, patients who have been dissatisfied with these methods or other oral drugs may sometimes be successfully treated with Sildenafil. The diversity of therapeutical options should, however, be used for combining methods in order to successfully treat all patients suffering from erectile dysfunction. It goes without saying that primary or concomitant psychotherapy or couple therapy should not be left out.

Intracavernous injection of prostaglandin E1 in combination with papaverine: enhanced effectiveness in comparison with papaverine plus phentolamine and prostaglandin E1 alone.

We compared the erectile response to intracavernous injection of a combination of papaverine and prostaglandin E1 with that of a combination of papaverine and phentolamine (49 patients), and prostaglandin E1 alone (38). The degree of erection achieved was significantly better with papaverine plus prostaglandin E1 than with papaverine plus phentolamine and the duration of erection was less, although the incidence of prolonged erections (greater than 5 hours) was similar with both combinations. Papaverine with prostaglandin E1 likewise resulted in a significantly better degree of erection than prostaglandin E1 alone (prolonged erections occurred only after the drug combination). All erections subsided spontaneously and none required medical intervention throughout the study. Pain was noted only after injection of prostaglandin E1. The incidence was clearly lower (7 of 38 versus 13 of 38) after the injection of only 5 micrograms. prostaglandin E1 in combination with papaverine (although the difference is not statistically significant). Subjectively, the side effects caused by the drug combination were described as much less dramatic by the patients than after prostaglandin E1 alone. The combination of papaverine and prostaglandin E1 shows a clearly synergistic effect and might suitably replace papaverine plus phentolamine or prostaglandin E1 alone in patients who do not respond well or suffer side effects after high single doses.

Efficiency and side effects of prostaglandin E1 in the treatment of erectile dysfunction.

The efficiency and side effects of a single dose of intracorporeally applied prostaglandin E1 (20 mcg.) in inducing penile erection were examined. In addition, the effect of this dose of prostaglandin E1 was compared to the effect of 7.5 mg. papaverine plus 0.25 mg. phentolamine in a double-blind, crossover designed study. We tested twice 12 men 52.9 +/- 7.6 years old (mean +/- standard deviation) with erectile dysfunction. On 1 occasion the subjects received 20 mcg. prostaglandin E1 and on the other they received 7.5 mg. papaverine and 0.25 mg. phentolamine. At this dosage prostaglandin E1 was most effective in inducing artificial penile erection (11 of 12 patients). However, 75 per cent of the subjects reported burning sensations during the entire period of erection and in 1 prostaglandin E1 treatment resulted in a sustained erection. At the doses used, prostaglandin E1 was more effective in inducing penile erection than papaverine plus phentolamine (11 versus 6 patients). Intracavernous injection of prostaglandin E1 is a potent tool for artificial penile erection and warrants precise examination for its potential clinical use.

Dose-dependent effect and side-effect of prostaglandin E1 in erectile dysfunction.

1. Recent work has demonstrated artificial penile erection after intracavernous injection of prostaglandin E1 (PGE1). A possible dose-response relationship between PGE1 and its erectile action was examined in a double-blind, cross-over designed, placebo-controlled study. 2. Twenty patients aged (mean +/- s.d.) 45 +/- 10.5 years suffering from psychogenic erectile dysfunction were tested on four occasions. Subjects received four intracavernous injections of saline containing either no other substance, preservative, 5 micrograms or 10 micrograms PGE1. 3. Investigations revealed clear dose-dependency of PGE1 in the grade and duration of erection achieved as well as in the latency between injection and achievement of erection (P less than 0.001). Saline and preservative did not induce erection. 4. Some local pain of varying grades did occur in 11/20 patients after 5 micrograms PGE1 and in 14/20 patients after 10 micrograms PGE1 injected intracavernously. This side-effect was caused by PGE1 itself and also showed a clear dose-relation (P = 0.0035). 5. Prostaglandin E1 appears to be a promising substance for diagnostic and therapeutic purposes in erectile dysfunction. Despite the discomfort observed in some patients, PGE1 is very effective even in low doses. PGE1 10 micrograms is suggested as the appropriate initial diagnostic dose for intracavernous injection to differentiate between the normal and pathological cavernous-vascular system.

[Miction cystourethrography effected on-target by X-ray examinations and executed under physiological conditions (author's transl)]. / Durchleuchtungsgezielte Miktionszystourethrographie unter physiologischen Bedingungen

A conventional method in pediatric urology is recalled, regarding the investigation of obstructive mictiurition difficulties in males. The value of the voiding cystourethrogram, performed by means of fluoroscopy in standing position following excretory urography, is evaluated in fifty patients with the conventional method (retrograde cystourethrogram). According to the gratifying results and to the improved radiological technique, this method can now be suggested as a screening examination.

Analgesic nephropathy and phenacetin-induced transitional cell carcinoma - analysis of 300 patients with long-term consumption of phenacetin-containing drugs.

In 300 urological patients with long-term intake of phenacetin-containing compounds, renal (papillary necrosis, chronic interstitial nephritis) and extrarenal manifestations appeared after an average latency period of 20 years. Course and prognosis primarily depend on the successful cessation of analgesics and the elimination of the accompanying infection. In the last decade, an increase of transitional cell carcinoma induced by analgesics has been observed. 31 of our patients presented a tumor of the urothelium (i.e. 10.3%) 26 patients presented isolated carcinoma of the bladder, 2 persons were diagnosed as having cancer of the bladder and the renal pelvis, and 1 patient had cancer of the bladder and the ureter. Only 2 persons suffered from isolated carcinoma of the renal pelvis. A further increase of these specific cases if expected.

Microsurgical arteriovenous revascularization in the treatment of vasculogenic impotence.

We studied 35 patients with vasculogenic impotence who underwent an operation since 1986 and who were followed postoperatively for a minimum of 1.5 years. In all patients a microsurgical anastomosis was performed between the inferior epigastric artery and the arteriovenous shunt of the dorsal penile vessels. Potency was restored or improved in 77% of the patients during the long-term observation. Doppler or duplex sonography confirmed the same percentage of patent anastomoses. Through microsurgical modifications of the Hauri procedure and the interposition of free venous grafts, it was possible to operate further in 3 patients with short epigastric arteries and to treat intraoperative complications effectively in 1.

[Therapeutic percutaneous puncture and drainage of postoperative space-occupying lesions using permanent ultrasound and roentgen control]. / Therapeutische, perkutane Punktion und Drainage postoperativer Raumforderungen unter permanenter Ultraschall- und Röntgensicht.

Ultrasonically guided, percutaneous fine-needle aspiration biopsy allows final histological and/or cytological diagnosis in patients with benign or malignant space-occupying growths even of small size. Therapeutic puncture and drainage of postoperative abdominal or retroperitoneal growths (haematoma, seroma, lymph cyst, abscess) however, requires 1.) dilatation of the percutaneously established puncture channel and 2.) continuous vacuum aspiration over a period of several days or weeks. We report on three therapeutic punctures in two patients with retroperitoneal lymph cysts following abdominal radical hysterectomy with lymphonodectomy and one patient with abscess formation following nephrectomy. The technique employed was as used in percutaneous nephrostomy. Under local anaesthesia and permanent ultrasound guidance the lesion is punctured with a 1.3 mm hollow puncture needle of three parts (Angiomed) and after aspiration of fluid a 0.9 mm wire guide with a curved, soft tap was inserted through the puncture needle in the lesion. The puncture channel is then dilated under x-ray visualisation with a Teflon-coated fasciadilatator (Cook) to Charr. 16 (20). Finally either a polyvinyl catheter with two lateral apertures (Cook) or a double-barrelled Shirley Drain is inserted and fixed to the skin with a stitch. For diversion a closed system is used. Over a period of one to two weeks 50 to 200 millilitres of secretion are drained off per day in decreasing quantity. The patients returned to normal temperature and recovered entirely. The advantage of our method is the avoidance of dangerous and difficult secondary surgery.

[Therapy of ureter lesions near the bladder (experiences with Boari plastic surgery)]. / Zur Therapie der blasennahen Ureterläsion (Erfahrungsbericht über Boari-Plastiken).

Report on the late results of 68 Boari plastic operations performed at least 4 years ago. Excellent results were achieved (normal urogramme, clinically free of pain) in 65% and satisfactory results (normal urogramme, subclinical infection of the urinary tract and/or vesicouteral reflux) in 8%. In 14 patients (27%) the results were not satisfactory. It appears that the Boari plastic operation continues to be a recommendable method for bridging major defects of the distal ureter.

Sex-dependent urolithiasis in the portacaval shunt rat. Part I.

Stone formation was investigated in 162 male and female Sprague-Dawley rats (96 males and 66 females) following a portacaval shunt and in 58 sham-operated rats which served as controls (31 males and 27 females). 70.8% male and only 7.5% female shunted rats developed urolithiasis. All stones of sufficient size were analyzed. The majority of stones in shunt-operated rats were made of potassium hydrogen urate (23/41), 10 rats had struvite stones without urinary tract infection, the remaining 8 rats had composite stones. Analysis of all stone-bearing control animals revealed struvite stones (6/6). Postoperatively, the rats developed polyuria, elevated potassium and uric acid excretion (all sex dependent). Urinary pH levels did not change significantly. Organ changes (atrophy of the liver, the testes and ovaries, hypertrophy of the kidney and the adrenal glands) were significant and differed according to sex. The role of sex hormones and prostaglandins is discussed.