[Treatment mapping of prostate cancer in DVPZ prostate centers in Germany]. / Versorgungsabbild zum Prostatakarzinom in DVPZ-Prostatazentren in Deutschland.

BACKGROUND: In prostate centers of the Governing Body of German Prostate Centers (DVPZ, Dachverband der Prostatazentren Deutschlands e.V.) treatment data from 3 university clinics, 21 treatment clinics, 3 private clinics and 330 general practitioners incorporated under 22 certificates are collated, in order to document the quality and type of cross-sectoral and interdisciplinary treatment, in particular of prostate cancer (PCA) patients. METHODS: This analysis is based on the DVPZ UroCloud data sets from 20 July 2015. The UroCloud reflects the web-based chronological disease development and quality parameters. For the descriptive analysis of particular key figures, available complete data sets were selected. RESULTS: Of the centers 22 held a valid certificate and fulfilled all required case numbers and structural prerequisites at the primary certification or recertification. In three cases a reauditing led to requirements before certification. Since 2005 a total of 9650 PCA patients have been pseudonymized and followed up (41,247 follow-up forms, 4.3 forms per patient). In 2014 the median number of newly documented PCA patients was 61 per center (minimum 7 and maximum 295). Radical prostatectomy (RP) dominated with 4491 (56 %) cases followed by primary hormonal therapy (1210 cases, 15 %), irradiation (809, 10 %) and non-interventional therapy, such as active surveillance (AS) or watchful waiting (WW) in 760 cases (10 %). A prostate-specific antigen (PSA) reduction was documented in 50 % of the patients with a preoperative PSA value > 20, in 60 % of pT4 tumors and in 50 % of patients with a tumor Gleason score of 9-10. A positive incision margin (R+) was found in in 15 % of pT2 stages, 41 % of pT3 stages and 85 % of pT4 stages. A secondary intervention was documented in 6.5 % of RP. CONCLUSION: The DVPZ certificate reflects the complete spectrum of treatment of PCA patients. The strength of the certificate lies in the documentation of patient development and a simultaneous collation of quality parameters.

[Organ-preserving therapy in invasive bladder carcinoma]. / Organerhaltende Therapie des invasiven Harnblasenkarzinoms.

With the aim of organ preservation, transurethral resection with subsequent radiotherapy (until 1985) or combined radio- and chemotherapy (since 1986) was undertaken as part of a prospective trial in 175 consecutive patients (137 men, 38 women; mean age 65 [31-90] years) with invasive bladder carcinoma, tumour stage T1-4 N0-3 M0. All patients had a transurethral resection, followed 2-6 weeks later by definitive radiotherapy at a dose of 50.4 Gy to the bladder in 28 fractions. 85 patients simultaneously with the radiotherapy received chemotherapy with cisplatin (25 mg/m2 daily) or carboplatin (65-75 mg/m2 daily) in the first and fifth weeks of radiotherapy. The 5-year survival rate for the whole group (including inoperable cases) was 50%. The survival rate as related to the T category was 53% for T1 (n = 26), 68% for T2 (n = 34), 45% for T3 (n = 94) and 22% for T4 (n = 17). 139 patients (79%) were left with a normally functioning bladder. Cystectomy was performed in 36 patients because of remaining tumour or recurrence after radiotherapy. Combined radio- and chemotherapy improved the histological remission rate, compared with an earlier control group with radiotherapy only, but it did not affect the survival rate. These data indicate that in advanced bladder carcinoma organ-preserving treatment with transurethral resection and definitive radiotherapy or combined radio- and chemotherapy can be successful.

[Clinical aspects and assessment of renal oncocytomas]. / Klinik und Wertigkeit renaler Onkozytome.

Oncocytomas represent a special category of renal tumors which can be clearly separated from the renal cell carcinomas by their typical histological presentation as well as by their clinical course. A clear cut preoperative diagnosis based on sonography, CT and angiography, however, is not yet possible. Between 1981 and 1990 16 patients (4 men, 12 women) with a mean age of 65 years underwent a radical tumor nephrectomy, with the histopathological diagnosis of an oncocytic adenoma, whose clinical and pathomorphological parameters were completely evaluated. Oncocytomas are rare, although increasingly found, tumors of the kidney with a benign clinical course. Up to date the treatment for these tumors has been nephrectomy, only rarely extirpation.

Radiotherapy with and without cisplatin in bladder cancer.

From October 1985 to December 1988, 67 patients with invasive bladder carcinoma T1-4 N0-2 M0 were treated with irradiation (50.4 Gy in 28 fractions in 6 weeks) and simultaneous cisplatin (25 mg/m2 per day on 5 consecutive days in the first and fifth irradiation week). After transurethral resection and irradiation plus cisplatin, complete remissions were achieved in 8/11 T1-, 14/16 T2-, 27/36 T3- and 1/4 T4-tumors. The complete remission rate 6 weeks after treatment according to the extent of preceeding transurethral surgery (TUR) was: R0: 67% (8/12); R1: 83% (20/24); R2: 70% (21/30); Rx: 1/1. In patients with incomplete TUR (R1-2), the complete remission rate was 76% (41/54). This was superior to the results of a historical control (76% vs. 45%, p less than 0.01). The estimated 3-year survival according to T-stage was: T1: 73%, T2-3: 68%, T4: 25%. The overall 3-year survival was unchanged as compared to our historical control (66% each). Severe complications have not been observed. We conclude that cisplatin will likely increase the local control rate after incomplete transurethral surgery. An improvement of survival seems unlikely.

[Induction of urinary bladder urothelial cancers in the rabbit by dibutylnitrosamine with an artificial bladder calculus as cocarcinogen]. / Induktion von Harnblasen-Urothelkarzinomen beim Hasen durch Dibutylnitrosamin mit künstlichem Blasenstein als Co-Karzinogen.

Thirteen rabbits received liquid dibutylnitrosamine (DBN) s.c. at a dosage of 400 mg/kg body weight once a week for a maximum of 16 months to induce transitional cell carcinomas (TCC) of the bladder. In five of these rabbits, 4 months after starting the injection of DBN an artificial stone prepared from a methylmethacrylate 2-component plastic material was implanted into the bladder. Four rabbits developed TCC of the bladder, with latency periods of 15-18 months. These tumors were found in two of the five (40%) rabbits with stones and in two of the eight (25%) rabbits without stones. The stone-bearing animals had more deeply infiltrating tumors, although the tumor induction times were comparable. Within a maximum observation period of 28 months there were no lymphogenous or hematogenous metastases. Another two rabbits showed benign urothelial changes presenting as simple hyperplasia and von Brunn's nests after 4 and 4.5 months, respectively. In two rabbits we found malignant tumors located extravesically, in the lungs and the kidney. The results of our study confirm the feasibility of TCC induction in rabbits by DBN administered s.c. Additional implantation of an artificial bladder stone acting as a co-carcinogen does not lead to a larger number of tumors, but does seem to enhance the degree of TCC induction in the bladder.

Impalpable testicular tumors diagnosed by scrotal ultrasonography.

Intrascrotal masses can be identified with a high degree of accuracy using scrotal ultrasonography. Ultrasound, however, is useful to identify occult and incidental testicular neoplasms, too. We report 2 cases of impalpable incidental testis germ cell tumors diagnosed by routine scrotal ultrasonography. One of the 2 patients had an incidental sequential second primary testicular germ cell tumor in the palpably normal testis, identified by routine follow-up ultrasound three months after contralateral radical orchiectomy.

Preliminary results of treatment of invasive bladder carcinoma with radiotherapy and cisplatin.

From October 1985 to February 1988, 41 patients with invasive bladder cancers were treated with transurethral resection (TUR) and radiotherapy with simultaneous cisplatin chemotherapy at the University Hospital in Erlangen. Radiotherapy was performed as primary treatment in case of macroscopic residual tumor after TUR (n = 22) or as adjuvant treatment in patients with macroscopically complete transurethral resection (n = 19). Age ranged from 44 to 77 years. Radiotherapy was given in daily fractions of 1.8 Gy. The pelvis was treated with a box up to 41.4 Gy and the bladder was boosted up to 50.4 Gy by a rotation technique. Cisplatin was administered in the first and fifth treatment week on five consecutive days with 25 mg cisplatin/m2 per day as short infusion. Pathohistologic response was examined by control cystoscopy with biopsies from the deep layers 6 weeks after completing radiochemotherapy. Maximum follow-up is 24 months after control cystoscopy. After TUR plus radiochemotherapy, histologically confirmed complete remission rates according to T-stage were: 7/8 T1-, 26/31 T2-3-, and 2/2 T4-tumors. In patients with macroscopic tumor prior to radiochemotherapy, histological and cytological complete remission was achieved in 2/3 T1-, 14/18 T2-3-, and 1/1 T4-cancers with an overall complete response rate of 77%. In complete responders, 3 isolated local recurrences (2 T1- and one T3-recurrence) and two local recurrences with distant metastases have occurred until now. Six patients had only partial response. Mild to moderate side effects occurred frequently, but overall treatment tolerance was good even in older patients. Complications did not occur. So far, 7 cystectomies have been performed, 6 were a result of persistent or recurrent tumor and one a result of a contracted bladder after multiple TURs. Thirty-four of forty-one patients (83%!) maintained their bladder and normal bladder function. In conclusion, moderate dose radiation therapy (50 Gy) in combination with simultaneous cisplatin chemotherapy is a well-tolerated treatment and highly effective for controlling local disease and preservation of bladder function in invasive bladder cancers.

[Increased quality of the donor kidney due to en bloc binephrectomy (author's transl)]. / Erhöhte Qualität des Nierentransplantats mittels en bloc-Binephrektomie bei dissoziiertem Hirntod.

The en bloc removal of both cadaver kidneys, approached transperitoneally, offers the following advantages in comparison with the separate bilateral technique: 1. Easy exposure of the renal artery and vein, even in the case of multiple renal vessels. -- 2. A venous and arterial patch of sufficient size is always available, facilitating the vascular anastomosis and reducing risk of vascular stenosis. -- 3. Damage due to ischemia is avoided or minimized by means of intraoperative perfusion. -- 4. Damage to the intima of the renal artery is avoided inasmuch the aorta instead of the renal artery is perfused. -- 5. Whenever a longterm perfusion by machine is considered, a rapidly constructed aortic conduit helps to avoid a potential damage to the intima of the renal artery by direct cannulation. -- 6. Separate mediocolonic removal of either kidney yields comparable results except the risk of damage to the intima. -- 7. A modification of the method is indicated, when both pancreas and kidneys are to be removed.

[Urological relevance of pelvic fractures]. / Urologische Relevanz der Beckenfraktur.

1. Apparently it is the anatomical difference of the paravesical structures which determines, whether a pelvic fracture will result in urological complications or not. The more the urogenital diaphragm is involved, the less is the risk of urological complications. The type of pelvic fracture and the magnitude of the trauma are of minor importance. 2. With respect to pathology and typology, one has to differentiate between incomplete and complete disruption of the urethra. The more pronounced the rupture is, the more the distal stump will retract back into the injured urogenital diaphragm. The longitudinal rupture splits the anterior wall of the urinary bladder and prostate; the rupture may extend into the membranaceous urethra. 3. Bleeding from the urethral meatus and the endogenous cystogram yield the most to the diagnosis of urological complications of a pelvic fracture. 4. The therapy is twofold. In the case of complete urethral disruption and dehiscence of the bony fragments, operative transvesical atraumatic splinting of the urethra by means of a Foley catheter is indicated. In the case of incomplete urethral rupture, transurethral insertion of a Foley catheter is usually sufficient and successful. 5. The results of the various therapeutical approaches equal the original extent of the urological complication. In addition to a certain degree of posttraumatic urethral stricturing, there are five further well defined sequelae of late urethral injuries.

[Evaluation of renal cyclic adenosine monophosphate, serum parathyroid hormone and phosphate reabsorption in recurrent calcium urolithiasis, healthy controls and hyperparathyroidism (author's transl)]. / Bewertung von renalem zyklischen Adenosinmonophosphat, Serum-Parathormon und Phosphat-Rückresorption bei rezidivierender Calcium-Urolithiasis, Gesunden und Hyperparathyreoidismus.

In three groups (n = 12 each) of male controls (22--43 years), patients with recurring calcium urolithiasis (21--36 years) and hyperparathyroidism (HPT; 17--71 years) proven by surgery renal cyclic adenosine monophosphate (RcAMP), fractional tubular phosphate reabsorption and serum parathyroid hormone (PTH) were measured during endogenous creatinine clearance. RcAMP (muMol/g creatinine) was: controls 1.48 +/- SEM 0.27; stone formers 2.037 +/- 0.343 (not significantly different); HPT 6.234 +/- 0.454 (p less than 0.001). There is no overlap between HPT and controls. Phosphate reabsorption is least in HPT (0.84 +/- 0.015), higher in controls (0.924 +/- 0.004) and stone formers (0.941 +/- 0.007). All differences are statistically significant. Under the conditions selected (moderate hydration of individuals) Serum PHT (pg-equiv/ml) is lowest in stome formers (less than 100--339), higher in controls (less than 100--933) and HPT (400--1150). there is no overlap in PHT between the former and the latter group but a marked one between controls and HPT. For clinical purposes the resulting diagnostic uncertainty in a given patient can be overcome by additional determinations of RcAMP and ionised serum calcium: when referring to serum PTH HPT patients fall outside, RCU patients within 2 standard deviations of either parameter in control subjects. This procedure presently appears superior to those proposed in the past (urinary cAMP etc.) but requires confirmation in larger patient populations. Moreover, since HPT prevails in middle and upper age decades, their RcAMP values and those of RCU patients should be related to a range seen in closely age- and sex-matched controls.

Urinary sodium and calcium in various dog models and relationship to endogenous plasma glucagon.

Clearance studies were performed in 23 dogs undergoing extracellular volume (ECV) expansion by saline in order to evaluate relationship between endogenous glucagon and renal excretion of sodium and calcium. In control animals plasma glucagon (pG1) rose following 120 minutes of ECV expansion and was further increased by additional infusion of arginine. In pancreatectomised dogs ECV expansion failed to increase pG1. Both fractional and absolute urinary excretion of sodium in pancreatectomised dogs were markedly lower compared to control dogs. The difference in renal sodium excretion between control and pancreatectomised animals cannot be explained by the sum of nonhormonal factors influencing sodium excretion. In thyro-parathyroidectomised dogs renal sodium excretion was lower than in control dogs, but significantly higher than in pancreatectomised dogs. The arginine-induced increase of glucagon was associated with an increase of renal sodium and calcium excretion in each group under study without any change in glomerular filtration rate. In control dogs all parameters of renal sodium and calcium excretion investigated in this study were linearly correlated. Thyro-parathyroidectomy did not influence the relationship between renal sodium and calcium excretion. Hyperglucagonaemia therefore might be one factor contributing to the hypercalciuria associated with renal stone formation. In pancreatectomised dogs undergoing ECV expansion there was no significant correlation between renal sodium and calcium excretion. Pancreatic hormones might be involved in the coupling of renal sodium and calcium excretion.

Fasting urine excretion of magnesium, calcium, and sodium in patients with renal calcium stones.

Urine excretion of magnesium (Mg), calcium (Ca) and sodium(Na) was studied in patients with renal Ca stones having normal kidney function (n= 60), and in matched controls (n= 60), on a free diet following an overnight fasting period. In some formers, Mg was lower than in normals, whereas Ca was unusually high resulting in a significantly higher molar Ca/Mg ratio (p less than 0.001). 2. In 3 out of 4 stone groups Na excretion was significantly elevated because of reduced tubular reabsorption. In normals, fractional Na excretion varied between 0.44 and 0.54% of endogenous creatinine clearance, whereas it exceeded 1% in the stone patients. Conversely, the molar ratio Na/Ca was equal in all groups. 3. Fasting urinary cyclic AMP was comparable in both populations supporting the assumption that in the majority of patients Ca- or Mg- wasting via urine may not be responsible for secondary hyperparathyroidism. In small selected groups, losses of divalent cations may act in concert, leading to stimulation of the parathyroid glands. 4. Correlations between minerals and Na reveal a close relationship between Na, Ca and Mg in terms of clearance and excretion rate in patients and controls. Fractional Na and Ca excretion are correlated in patients but not in normals. This suggests that in the absence of phosphaturia, factors other than extracellular volume expansion and/or hyperparathyroidism are operative in stone disease. 5. The origin of fasting natriuresis and relative hypercalciuria may be ascribed to a change, as yet not causally identified, in distal tubular Na reabsorption.

Ultrafiltrable uric acid in serum of healthy humans and patients with renal calcium lithiasis.

Ultrafiltrable serum uric acid (u.a.) was determined by ultrafiltration under in vivo conditions in humans using a reliable technique described in detail. It could be demonstrated that u.a. binding to macromolecules occurs in healthy humans (controls) and in patients with renal calcium stones. The percentage of free u.a. in controls (n=60) averages 86.2 +/- 0.9 SEM. With increasing age, bound u.a. rises slightly. On the other hand, younger (less than 40 years) stone patients have significantly more bound u.a. than matched controls (80.7 +/- 1.0 SEM; p less than 0.001), whereas this is not found in elderly patients. The degree of binding is not related to concentration of plasma proteins but inversely related to free fatty acid concentration in healthy controls (r= -0.52; p less than 0.01). It is suggested that no augmentation of tubular u.a. filtered by the glomeruli could have occurred. The origin of fasting hyperuricosuria shown earlier to be a prominent feature of young renal calcium stone formers is yet unknown.