Impact of surgeon's experience on outcome parameters following ureterorenoscopic stone removal.

Within the BUSTER trial, we analyzed the surgeon's amount of experience and other parameters associated with URS procedures regarding the stone-free rate, complication rate, and operative time. Patient characteristics and surgical details on 307 URS procedures were prospectively documented according to a standardized study protocol at 14 German centers 01-04/2015. Surgeon's experience was correlated to clinical characteristics, and its impact on the stone-free rate, complication rate, and operative time subjected to multivariate analysis. 76 (25%), 66 (21%) and 165 (54%) of 307 URS procedures were carried out by residents, young specialists, and experienced specialists (> 5 years after board certification), respectively. Median stone size was 6 mm, median operative time 35 min. A ureteral stent was placed at the end of 82% of procedures. Stone-free rate and stone-free rate including minimal residual stone fragments (adequate for spontaneous clearance) following URS were 69 and 91%, respectively. No complications were documented during the hospital stays of 89% of patients (Clavien-Dindo grade 0). According to multivariate analysis, experienced specialists achieved a 2.2-fold higher stone-free rate compared to residents (p = 0.038), but used post-URS stenting 2.6-fold more frequently (p = 0.023). Surgeon's experience had no significant impact on the complication rate. We observed no differences in this study's main endpoints, namely the stone-free and complication rates, between residents and young specialists, but experienced specialists' stone-free rate was significantly higher. During this cross-sectional study, 75% of URS procedures were performed by specialists. The experienced specialists' more than two-fold higher stone-free rate compared to residents' justifies ongoing efforts to establish structured URS training programs.

[Molecular characterization of penile cancer : Literature review of new prognostic markers and potential therapeutic targets]. / Die molekulare Charakterisierung des Peniskarzinoms : Literaturreview zu neuen Prognosemarkern und potentiellen Therapietargets.

Squamous cell carcinoma of the penis (SCCP) is a rare cancer type in Western industrialized nations; nevertheless, it shows an aggressive course of disease in advanced tumor stages with accordantly high recurrence and progression rates. While molecular biomarkers are not established in clinical routine for the management of SCCP patients yet, the accordant unmet need is enormous, as adequate biomarkers would be meaningful for prognostic determination, planning of modality and extent of primary therapy, indication for inguinal lymph node resection, adjuvant treatment, and as potential targets for specific systemic treatment. SCCP regularly develops from a precursor lesion. In this regard, human papillomavirus (HPV)-dependent and -independent pathways are differentiated. The potential for specific target therapy options is mainly based on the decoding of genetic and epigenetic signatures of distinct molecular pathways. In order to develop targeted and personalized treatment strategies based on molecular pathways, an increase in translational research in large multi-institutional collaborations must be promoted. This review article aims to summarize the current status of research concerning molecular changes related to SCCP under separate consideration of prognostic molecular markers, on the one hand, and biomarkers considered potential therapeutic targets, on the other hand. In addition, previous research activities of our own working group on this topic are briefly described.

Prognostic significance of Fuhrman grade and age for cancer-specific and overall survival in patients with papillary renal cell carcinoma: results of an international multi-institutional study on 2189 patients.

PURPOSE: Because the prognostic impact of the clinical and pathological features on cancer-specific survival (CSS) and overall survival (OS) in patients with papillary renal cell carcinoma (papRCC) is still controversial, we want to assess the impact of clinicopathological features, including Fuhrman grade and age, on survival in surgically treated papRCC patients in a large multi-institutional series. METHODS: We established a comprehensive multi-institutional database of surgically treated papRCC patients. Histopathological data collected from 2189 patients with papRCC after radical nephrectomy or nephron-sparing surgery were pooled from 18 centres in Europe and North America. OS and CSS probabilities were estimated using the Kaplan-Meier method. Multivariable competing risks analyses were used to assess the impact of Fuhrman grade (FG1-FG4) and age groups (<50 years, 50-75 years, >75 years) on cancer-specific mortality (CSM). RESULTS: CSS and OS rates for patients were 89 and 81% at 3 years, 86 and 75% at 5 years and 78 and 41% at 10 years after surgery, respectively. CSM differed significantly between FG 3 (hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.17-8.22; p < 0.001) and FG 4 (HR 8.93, 95% CI 4.25-18.79; p < 0.001) in comparison to FG 1. CSM was significantly worse in patients aged >75 (HR 2.85, 95% CI 2.06-3.95; p < 0.001) compared to <50 years. CONCLUSIONS: FG is a strong prognostic factor for CSS in papRCC patients. In addition, patients older than 75 have worse CSM than patients younger than 50 years. These findings should be considered for clinical decision making.

[Rates of prostate-specific antigen testing for early detection of prostate cancer: a first comparison of German results with current international data]. / PSA-basierte Früherkennung des Prostatakarzinoms durch den Hausarzt: Erste deutsche Ergebnisse im internationalen Vergleich.

OBJECTIVE: Measurement of prostate-specific antigen (PSA) is not only used as a screening instrument by urologists, but also by general practitioners and internal specialists (GP-IS). Until now, there are neither data on the approach of German GP-IS in practicing this nor have data been classified in the context of available international literature on this topic. MATERIALS AND METHODS: Between May and December 2012, a questionnaire containing 16 items was sent to 600 GP-IS in Brandenburg and Berlin. The response rate was 65% (392/600). Six indicator questions (IQ1-6) were selected and results were set in the context of available international data. The quality of present studies was evaluated by the Harden criteria. RESULTS: Of the 392 responding physicians, 317 (81%) declared that they would use PSA testing for early detection of PCA (IQ1) and, thus, formed the study group. Of these GP-IS, 38% consider an age between 41 and 50 years as suitable for testing begin (IQ2), while 53% and 14% of the GP-IS perform early detection until the age of 80 and 90 years, respectively (IQ3). A rigid PSA cut-off of 4 ng/ml is considered to be reasonable by 47% of the involved GP-IS, whereas 16% prefer an age-adjusted PSA cut-off (IQ4). Patients with pathological PSA levels were immediately referred to a board-certified urologist by 69% of the GP-IS. On the other hand, 10% first would independently control elevated PSA levels themselves after 3-12 months (IQ5). Furthermore, 14% of the interviewed physicians consider a decrease of PCA-specific mortality by PSA screening as being proven (IQ6). Knowledge regarding PCA diagnostics is mainly based on continuous medical education for GP-IS (33%), personal contact with urologists (6%), and guideline studies (4%). While 53% indicated more than one education source, 4% did not obtain any PCA-specific training. The results provided by this questionnaire evaluating response of German GP-IS to six selected indicator questions fit well into the international context; however, further studies with sufficient methodical quality are required. CONCLUSIONS: Despite current findings and controversial recommendations of the two large PCA screening studies on this issue, German GP-IS still frequently use PCA screening by PSA measurement. Primary strategies of early detection as well as follow-up after assessment of pathologically elevated PSA levels poorly follow international recommendations. Thus, an intensification of specific education is justified.

Muscle-derived cells for treatment of iatrogenic sphincter damage and urinary incontinence in men.

INTRODUCTION: Aim of this study was to assess the safety and efficacy of injection of autologous muscle-derived cells into the urinary sphincter for treatment of postprostatectomy urinary incontinence in men and to characterize the injected cells prior to transplantation. METHODS: 222 male patients with stress urinary incontinence and sphincter damage after uroloical procedures were treated with transurethral injection of autologous muscle-derived cells. The transplanted cells were investigated after cultivation and prior to application by immunocytochemistry using different markers of myogenic differentiation. Feasibility and functionality assessment was achieved with a follow-up of at least 12 months. RESULTS: Follow-up was at least 12 months. Of the 222 treated patients, 120 responded to therapy of whom 26 patients (12%) were continent, and 94 patients (42%) showed improvement. In 102 (46%) patients, the therapy was ineffective. Clinical improvement was observed on average 4.7 months after transplantation and continued in all improved patients. The cells injected into the sphincter were at least ~50% of myogenic origin and representative for early stages of muscle cell differentiation. CONCLUSIONS: Transurethral injection of muscle-derived cells into the damaged urethral sphincter of male patients is a safe procedure. Transplanted cells represent different phases of myogenic differentiation.

A phase II trial of temsirolimus in second-line metastatic urothelial cancer.

This phase II trial assessed temsirolimus, an inhibitor of mammalian target of rapamycin (mTOR), as second-line therapy in patients with metastatic transitional carcinoma of the urothelium (TCCU) after failure of platinum containing therapy. From June/2009 to June/2011, we enrolled 15 patients in this trial. Primary endpoint was overall survival, as secondary endpoints we defined time to disease progression, safety and QoL along treatment. Patients with progressive TCCU after prior platinum-based chemotherapy received weekly 25 mg of temsirolimus for 8 weeks. Evaluation for response was accomplished every 8 weeks according to the RECIST criteria, QoL assessment was done every 4 weeks using the QLQ-C30 questionnaire, adverse events (AEs) were recorded and graded using NCI-CTC criteria. Fifteen patients were enrolled in this study, of whom 14 (93%) were available for activity, safety and QoL assessment. We treated 10 (71%) male and 4 female (29%) patients. Median age was 64,7 years (45-76). Patients received on average 13 (3-15) infusions of temsirolimus. As per protocol, no sufficient benefit on overall survival was observed, we early stopped the study after 14 patients. Median time to progression was 2.5 months (77 days), median overall survival was 3.5 months (107 days). Four patients with stable disease were observed. QoL assessment along treatment revealed a reduction of EORTC-QLQ-C30, Global Health Status subscale, from initial 7.86 to 5.00. Temsirolimus was well tolerated. As Grade 3-4 adverse events, we observed fatigue (n=2), leukopenia (n=2) and thrombopenia (n=2). All other adverse events were graded 1-2 in nature. Temsirolimus seems to have poor activity in patients with progressive metastasized TCCU after failure of platinum containing first-line therapy.

Dural metastases from disseminated prostate cancer clinically mimicking a benign reactive condition of the dura: case report and review of the literature.

Dural spread from prostate cancer (PC) is exceedingly uncommon. We report on a 62-year-old man suffering from disseminated PC with osseous metastases who presented with a parietal skull metastasis along with a circumscribed nodular thickening of the adjacent dura. Magnetic resonance imaging findings suggested a benign reactive condition of the dura which, however, histologically turned out to be a dural metastasis. Therefore, the present case report stresses the notion that very rarely, disseminated PC might present with clinically unsuspected dural metastases radiologically mimicking a benign condition.

mTOR-inhibition in metastatic renal cell carcinoma. Focus on temsirolimus: a review.

The potent inhibitor of the mammalian target of rapamycin, temsirolimus, comprises for cell cycle, angiogenesis and proliferation and has proven beneficial in the treatment of advanced renal cell carcinoma (RCC). Temsirolimus is officially approved for first line therapy in high risk previously untreated mRCC patients. This review summarizes the current clinical role of temsirolimus in the treatment of advanced renal cell carcinoma with regard to pharmacological features, toxicity and tolerability. It particularily discusses quality of life issues as important outcome parameters in palliative treatment of patients with mRCC and gives an outlook on current clinical developments regarding possible future combining/ sequencing strategies of temsirolimus.

What happens if nothing happens?--History of an untreated urothelial carcinoma of the bladder.

UNLABELLED: Bladder cancer is controllable when adequately diagnosed and treated according to current recommendations. Radical cystectomy with urinary diversion is the standard therapy for muscle invasive tumors. In patients unfit or unwilling to get radical surgery, external beam or combined chemo-radiotherapy display alternative treatment options and can be safely performed. Every therapy implies the patient's disposition to cooperate. CASE PRESENTATION: This case report describes the clinical course over 31 months after initial diagnosis of a 56-years-old Caucasian, white man with an initial pT1G3 urothelial carcinoma of the bladder. The patient denied early radical cystectomy, radio-chemotherapy and almost all alternative treatment possibilities. He finally died 31 months after initial verification of the disease.

Gemcitabine, paclitaxel, and cisplatin as combined adjuvant approach in transitional cell carcinoma of the urothelium.

AIM: The objective of this study was to evaluate the adjuvant chemotherapy with gemcitabine, paclitaxel, and cisplatin for urothelial carcinoma. METHODS: Twenty-seven patients with invasive transitional cell carcinoma of the urothelium were treated between 2001 and 2007. All patients received chemotherapy with intravenous gemcitabine at a dose of 1000 mg/mC on Days 1 and 8, intravenous paclitaxel at a dose of 80 mg/mC on Days 1 and 8, and intravenous cisplatin at a dose of 50 mg/mC on Day 2. Treatment courses were repeated every 21 days. RESULTS: Median follow-up period was 32.5 months. Six patients came to progressive disease. The median overall survival was not reached, and the actuarial 1-year and 2-year survival rates were 89% and 67% respectively. The median progression-free survival was 10.0 months. Median survival time for patients with ECOG status 0, and 1 was 52.0, and 22.0 months respectively. Grade 4 neutropenia occurred in 18.5% of patients, but there was no treatment related mortality. CONCLUSIONS: The combination of gemcitabine, paclitaxel, and cisplatin is a highly effective and tolerable regimen for patients with invasive transitional cell carcinoma of the urothelium. This treatment should be considered as a suitable option that deserves further prospective evaluation. ECOG performance status is an important predictive factors for survival.

Palliative chemotherapy with gemcitabine, paclitaxel, and cisplatin as first-line treatment following gemcitabine monotherapy for patients with transitional cell carcinoma of the urothelium.

AIM: Chemotherapeutic agents are active in transitional cell cancer of the urothelium, and combinations have shown promising results. The objective of this study was to evaluate the palliative chemotherapy with gemcitabine, paclitaxel, and cisplatin for transitional cell carcinoma. METHODS: Thirty-four patients with advanced transitional cell carcinoma of the urothelium were treated between 2000 and 2007. All patients received chemotherapy with intravenous gemcitabine at a dose of 1000 mg/m2 on days I and VIII, intravenous paclitaxel at a dose of 80 mg/m2 on days I and VIII, and intravenous cisplatin at a dose of 50 mg/m2 on day II. Treatment courses were repeated every 21 days. After completion of four to six courses in this regimen an application of intravenous gemcitabine at a dose of 1000 mg/m2 followed repeating every 28 days. RESULTS: Twelve patients (35.3%) had 1 visceral sites of metastases. Twenty two patients (64.7%) had achieved objective responses to treatment (29.4% complete responses). The median actuarial survival was 18.5 months, and the actuarial one-year and two-year survival rates were 56% and 26% respectively. After a median follow-up of 16.3 months, 18 patients remained alive. The median progression-free survival was 7 months. Median survival time for patients with ECOG status 0, 1, and 2 was 45, 12, and 10.5 months respectively. Grade 3-4 neutropenia occurred in 41.2% of patients. CONCLUSIONS: The combination of gemcitabine, paclitaxel, and cisplatin is a highly effective and tolerable regimen for patients with advanced transitional cell carcinoma of the urothelium. This treatment should be considered as a suitable option that deserves further prospective evaluation. ECOG performance status and visceral metastases are important predictive factors for survival.

Focus on urinary bladder cancer markers: a review.

Finding and development of new bladder cancer markers is still a very dynamic field. Because of the mass of all these markers it is impossible to report all of them. This paper reviews the role of bladder cancer markers in diagnosis and highlights the most important biomarkers studied and reported recently. A medline based literature search was performed to examine the field of bladder cancer markers. Major topics focus on selected bladder cancer markers from nearly all categories of the wide field of bladder cancer markers: Hematuria, FISH, FGFR3, SURVIVIN, u-PAR, TP53 mutation, HER-2/neu, TPA, NMP22, CK-19, CK-20, CYFRA 21-1. The use and clinical importance as diagnostic help are discussed. In this review a highlight to some of the most important markers was made. Further determination of recurrence and progression marker will contribute to establish better treatments for the individual patient. Molecular staging of urological tumors will allow selecting cases that will require systemic treatment. It is necessary and important to integrate under the same objectives basic and clinical research.