Long-term functional success and patient-reported outcomes after female one-stage buccal mucosal graft urethroplasty.

INTRODUCTION AND OBJECTIVES: Female urethral strictures are a rare condition that significantly impacts patients' quality of life. Patient-reported outcomes are crucial, yet data regarding sexual function and treatment satisfaction are scarce. We aimed to provide insights from a reconstructive referral center. PATIENTS AND METHODS: We conducted a retrospective analysis of women treated with ventral onlay one-stage buccal mucosa graft urethroplasty for urethral strictures between 2009-2023. We assessed objective (retreatment-free survival, ΔQmax) and subjective outcomes (validated patient-reported outcomes). RESULTS: Of 12 women, 83% and 17% had iatrogenic and idiopathic strictures, respectively. Median number of prior interventions was 6. Strictures were located meatal and mid-urethral in 25% and 75%, respectively, 22% had the bladder neck involved. Median graft length was 2 cm. At median follow-up of 66 months, 33% of patients underwent stricture retreatment, but only one case occurred within the first 2 years postoperatively. The median improvement in maximum flow rate (ΔQmax) was 10 ml/s. Median International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules (ICIQ-FLUTS) scores were 8 for filling symptoms, 6 for voiding symptoms, and 3 for incontinence symptoms. Median ICIQ-FLUTSsex score was 4. Higher scores indicate a higher symptom burden. Median ICIQ-Satisfaction outcome and satisfaction scores were 18 and 7, respectively, reflecting high treatment satisfaction. CONCLUSIONS: Buccal mucosal graft urethroplasty by ventral onlay for female urethral strictures yields effective, durable, and positively received outcomes. However, larger studies across multiple institutions are necessary to further assess its efficacy, especially regarding patient-reported experiences and sexual function.

Vesico-urethral anastomotic stenosis following radical prostatectomy: a multi-institutional outcome analysis with a focus on endoscopic approach, surgical sequence, and the impact of radiation therapy.

OBJECTIVES: To investigate the predictors of recurrence and of de novo incontinence in patients treated by transurethral incision or resection for vesico-urethral anastomotic stenosis (VUAS) after radical prostatectomy. MATERIAL AND METHODS: All patients undergoing endoscopic treatment for VUAS between March 2009 and October 2016 were identified in our multi-institutional database. Digital chart reviews were performed and patients contacted for follow-up. Recurrence was defined as any need for further instrumentation or surgery, and de-novo-incontinence as patient-reported outcome. RESULTS: Of 103 patients undergoing endoscopic VUAS treatment, 67 (65%) underwent transurethral resection (TR) and 36 (35%) transurethral incision (TI). TI was performed more frequently as primary treatment compared to TR (58% vs. 37%; p = 0.041). Primary and repeated treatment was performed in 46 (45%) and 57 patients (55%), respectively. Overall, 38 patients (37%) had a history of radiation therapy. There was no difference in time to recurrence for primary vs repeat VUAS treatment, previous vs no radiation, TR compared to TI (all p > 0.08). Regarding treatment success, no difference was found for primary vs. repeat VUAS treatment (50% vs. 37%), previous radiation vs. no radiation (42% vs. 43%), and TR vs. TI (37% vs. 53%; all p ≥ 0.1). Postoperative de novo incontinence was more common after TI vs. TR (31% vs. 12%; p = 0.032), no difference was observed for previous radiation therapy vs. no radiation therapy (18% vs. 18%; p > 0.9) or primary vs. repeat VUAS treatment (22% vs. 16%; p = 0.5). CONCLUSION: VUAS recurrence after endoscopic treatment is not predictable. Endoscopic treatment with TI showed a higher risk for de novo incontinence than TR, and previous irradiation and the number of treatments do not influence incontinence.

[Vesicovaginal fistulas: diagnosis and surgical management]. / Vesikovaginale Fisteln: Diagnostik und operatives Management.

Vesicovaginal fistulas (VVF) represent a detrimental condition causing psychological, physical and social strain on patients. In developed countries they are predominantly the result of pelvic surgery or radiation therapy, whilst obstetric VVF are common in developing countries due to prolonged and complicated births. The majority of VVF require surgical therapy, thus a comprehensive diagnostic workup is needed. Depending on diagnostic characteristics fistula repair can be performed by a transvaginal, transabdominal or minimally invasive approach. Timing of surgery, appropriate interposition of vascularized grafts, optimized postoperative management and surgical expertise are determining factors for successful treatment. This review describes the diagnostic workup and therapeutic management of VVF including various surgical techniques.

[Fistula surgery]. / Fistelchirurgie.

Vesicovaginal fistulas are a rare problem in the western world but are frequent occurrences in developing countries. In Germany the most frequent cause is hysterectomy. Vesicovaginal fistulas can be treated by the transvaginal or transabdominal approach depending on the characteristics of the fistula and the patient. The incidence and complexity of urorectal fistulas increase with the number of cumulative sequences of prostate cancer treatment. Overall there is no clear consensus about the optimal surgical approach route. The surgical treatment of both vesicovaginal and urorectal fistulas is associated with high permanent fistula closure rates; however, for both entities if the fistula is discovered early enough, conservative treatment with a temporary catheter drainage can be tried, depending on the underlying cause. For both conditions fistula repair in irradiated patients shows a much lower success rate. A spontaneous closure of fistulas in radiogenic fistulas is also not to be expected.

[Positron emission tomography in germ cell tumors in men : Possibilities and limitations]. / Positronenemissionstomographie bei Keimzelltumoren des Mannes : Einsatzmöglichkeiten und Grenzen.

BACKGROUND: Conventional radiographic imaging may fail to safely distinguish clinical stage I from stage IIA germ cell cancer, to localize isolated tumor marker relapses, and to equivocally identify the viability of postchemotherapy residual masses. OBJECTIVES: To provide an overview of the diagnostic value and limitations of functional imaging by positron emission tomography with 2­deoxy-2-[fluorine-18]fluoro-D-glucose with computed tomography (18F-FDG-PET-CT) in male germ cell cancer. MATERIALS AND METHODS: A narrative review based on a literature search of PubMed/MEDLINE for original articles published from 1990-2018 and conference proceedings of ASCO (American Society of Clinical Oncology) and EAU (European Association of Urology) annual meetings 2014-2017 is presented. RESULTS: 18F-FDG-PET-CT does not improve diagnostic accuracy compared to conventional CT imaging clinical stage (CS) I disease. Particularly PET-negativity of postchemotherapy residual masses of seminomas >3 cm in size guide decision-making against further additional treatment. Even PET-positive residues must not result in relapse. For nonseminoma, the value of PET imaging is reduced by potential mature teratoma components, which are commonly PET negative. CONCLUSIONS: Current guidelines recommend 18F-FDG-PET-CT 6-8 weeks postchemotherapy for viability assessment of seminoma residues >3 cm in size. Exceptional circumstances, in which 18F-FDG-PET-CT may be helpful, include: (1) detection of active disease in CS IS, (2) viability assessment of residual masses >1 cm where complete secondary resection is impossible, (3) staging at marker relapse with unconspicuous conventional CT scan, (4) early response assessment during chemotherapy.

Cell-free DNA release under psychosocial and physical stress conditions.

The understanding of mechanisms linking psychological stress to disease risk depend on reliable stress biomarkers. Circulating cell-free DNA (cfDNA) has emerged as a potential biomarker of cellular stress, aging, inflammatory processes, and cell death. Recent studies indicated that psychosocial stress and physical exercise might also influence its release. We compared the effects of acute psychosocial and physical exercise stress on cfDNA release by exposing 20 young, healthy men to both an acute psychosocial laboratory stressor and an acute physical exercise stressor. Venous blood and saliva samples were collected before and after stress exposure. Cell-free DNA was extracted from plasma and quantified by qPCR. Furthermore, cfDNA fragment length was analyzed and cfDNA methylation patterns were assayed across time. In addition, release of stress hormones and subjective stress responses were measured. Results showed a twofold increase of cfDNA after TSST and fivefold increase after exhaustive treadmill exercise, with an overabundance of shorter cfDNA fragments after physical exhaustion. Interestingly, cell-free mitochondrial DNA showed similar increase after both stress paradigms. Furthermore, cfDNA methylation signatures-used here as a marker for diverse cellular origin-were significantly different post stress tests. While DNA methylation decreased immediately after psychosocial stress, it increased after physical stress, suggesting different cellular sources of active DNA release. In summary, our results suggest stimulus and cell-specific regulation of cfDNA release. Whereas the functional role of stress-associated cfDNA release remains elusive, it might serve as a valuable biomarker in molecular stress research as a part of the psychophysiological stress response.

Commentary on "Detection and oncological effect of circulating tumor cells in patients with variant urothelial carcinoma histology treated with radical cystectomy."

OBJECTIVES: To investigate for the presence of circulating tumor cells (CTC) in patients with variant urothelial carcinoma of the bladder (UCB) histology treated with radical cystectomy (RC), and to determine their impact on oncological outcomes. PATIENTS AND METHODS: We, prospectively, collected data of 188 patients with UCB treated with RC without neoadjuvant chemotherapy. Pathological specimens were meticulously reviewed for pure and variant UCB histology. Preoperatively collected blood samples (7.5ml) were analyzed for CTC using the CellSearch system (Janssen, Raritan, NJ). RESULTS: Variant UCB histology was found in 47 patients (25.0%), most frequently of squamous cell differentiation (16.5%). CTC were present in 30 patients (21.3%) and 12 patients (25.5%) with pure and variant UCB histology, respectively. At a median follow-up of 25 months, the presence of CTC and nonsquamous cell differentiation were associated with reduced recurrence-free survival (RFS) and cancer-specific survival (pairwise P ≤ 0.016). Patients without CTC had better RFS, independent of UCB histology, than patients with CTC with any UCB histology (pairwise P<0.05). In multivariable analyses, the presence of CTC, but not variant UCB histology, was an independent predictor for disease recurrence (hazard ratio = 3.45, P<0.001) and cancer-specific mortality (hazard ratio = 2.62, P = 0.002). CONCLUSION: CTC are detectable in about a quarter of patients with pure or variant UCB histology before RC, and represent an independent predictor for outcomes, when adjusting for histological subtype. In addition, our prospective data confirm the unfavorable influence of nonsquamous cell-differentiated UCB on outcomes.

Worth a second look: outcomes of patients with initial finding of regular renal tissue in CT-guided renal tumor biopsies.

INTRODUCTION AND OBJECTIVE: Renal tumor biopsy is recommended for histological diagnosis of radiologically indeterminate renal masses, to select patients with small-renal masses for surveillance approaches, before ablative treatments and to confirm metastatic spread of renal cell cancer (RCC), according to the EAU guidelines. We aimed to determine outcomes of patients with suspicious renal masses with initial finding of regular renal tissue in renal tumor biopsies. METHODS: Retrospective database analysis of 101 patients undergoing CT-guided-, percutaneous renal tumor biopsies in local anesthesia. RESULTS: In 23/101 patients, histopathologic evaluation of the biopsies showed regular renal tissue. Of these, two patients underwent simultaneous radiofrequency ablation (RFA), 2/23 underwent radical nephrectomy, despite negative biopsy because of radiological suspicious aspect. Overall, 12 patients underwent a second set of biopsies due to persistent clinical suspicion. Of these, five were diagnosed with RCC: three clear cell renal cell carcinoma (ccRCC) and two papillary renal cell carcinoma (pRCC). Benign tumours were found in two patients. A lymphoma was found in two patients. In 3/12 patients, also the second set of biopsies showed regular renal tissue. CONCLUSION: An unsuspicious histology in CT-guided renal tumor biopsy does not preclude patients with suspicious renal masses from being diagnosed with malignancies.

[Social Inequality in Utilization of Aftercare Services Among Breast and Prostate Cancer Patients]. / Soziale Ungleichheit bei der Inanspruchnahme onkologischer Versorgungsangebote.

OBJECTIVES: This study examines social inequalities in the utilization of medical rehabilitation, complementary and alternative medicine (CAM) and psychosocial support programs among patients with prostate and breast cancer after surgery. METHOD: A prospective, multicenter observational study was conducted. Subjects were 483 patients after primary manifestation of prostate and breast cancer (UICC-Stadium 0-IV) aged between 18 and 65 years. Patients were asked to fill out a questionnaire after surgery and 6 months later. Social inequality was measured by education, income and occupational status. In addition, the insurance status (private vs. statutory) was taken into account. Logistic regression models were used separately for each cancer site. The analyses were controlled for age, tumor stage and mental comorbidity. RESULTS: The associations between social inequality and the utilization of aftercare services vary by inequality indicator and the different health care services. Inequalities in utilization of CAM are most pronounced and consistent. Differences between status groups are small in utilization of rehabilitation. Among breast cancer patients, inequalities are more pronounced than among prostate cancer patients. CONCLUSION: Social inequalities in utilization of aftercare services among breast and prostate cancer patients are inconsistent. Future investigations should clarify to what extent such inequalities are due to access barriers or due to differences in health literacy or preferences.

[Redo urethroplasty with buccal mucosa]. / Redo-Harnröhrenplastik mit Mundschleimhaut.

Urethral strictures can occur on the basis of trauma, infections, iatrogenic-induced or idiopathic and have a great influence on the patient's quality of life. The current prevalence rate of male urethral strictures is 0.6% in industrialized western countries. The favored form of treatment has experienced a transition from less invasive interventions, such as urethrotomy or urethral dilatation, to more complex open surgical reconstruction. Excision and primary end-to-end anastomosis and buccal mucosa graft urethroplasty are the most frequently applied interventions with success rates of more than 80%. Risk factors for stricture recurrence after urethroplasty are penile stricture location, the length of the stricture (>4 cm) and prior repeated endoscopic therapy attempts. Radiation-induced urethral strictures also have a worse outcome. There are various therapy options in the case of stricture recurrence after a failed urethroplasty. In the case of short stricture recurrences, direct vision urethrotomy shows success rates of approximately 60%. In cases of longer or more complex stricture recurrences, redo urethroplasty should be the therapy of choice. Success rates are higher than after urethrotomy and almost comparable to those of primary urethroplasty. Patient satisfaction after redo urethroplasty is high. Primary buccal mucosa grafting involves a certain rate of oral morbidity. In cases of a redo urethroplasty with repeated buccal mucosa grafting, oral complications are only slightly higher.

[Renal cell carcinomas in childhood]. / Nierenzellkarzinome im Kindesalter.

BACKGROUND: Renal cell carcinoma is a rare childhood disease. However, it should be considered in the differential diagnosis in the detection of a renal mass. OBJECTIVES: Incidence and mortality of renal cell carcinomas in childhood. Presentation of clinical symptoms, diagnostics, histology, therapy and course of the disease. PATIENTS AND METHODS: Evaluation of our own prospective data of a small patient population of 8 patients, as well as discussion of the current literature on this tumor entity. RESULTS: The average follow-up period was 27 months. Preoperative staging studies showed no metastases. The histologically primary predominant subtype was papillary renal cell carcinoma. Tumor stage and lymph node status were the most important prognostic factors in our study. CONCLUSIONS: Renal cell carcinoma in childhood is a rare disease whose treatment is challenging and should be performed in an interdisciplinary team. Typical clinical symptoms, as in adults, are absent. The partial nephrectomy should be, if practicable, the surgical treatment of choice. The most important risk factors for survival are tumor stage and lymph node status. Data on adjuvant target therapy for metastatic disease in childhood are lacking. Further prospective, multicenter studies are necessary to generate more information on the biology and course of this disease and to obtain adjuvant treatment options in locally advanced disease.

[Early bilateral nephrectomy in neonatal autosomal recessive polycystic kidney disease : Improved prognosis or unnecessary effort?] / Frühe beidseitige Nephrektomie bei Säuglingen mit pränataler ARPKD : Prognoseverbesserung oder unnötiger Aufwand?

BACKGROUND: Neonatal autosomal recessive polycystic kidney disease (ARPKD) is associated with giant kidneys, lung hypoplasia, pulmonal hypertension, and end-stage renal failure. Depending on the study, mortality is reported to range between 20 and 80%. OBJECTIVES: Does bilateral nephrectomy improve survival? PATIENTS AND METHODS: Between 2010 and 2016, we treated 7 children with prenatally diagnosed ARPKD. All had a planned delivery by cesarean section. After birth, oscillated ventilation with nitrogen enrichment was initiated to achieve maximum oxygenation and to decrease pumonary hypertension. All children had bilateral massive kidney hyperplasia (length 13-16 cm). RESULTS: Nephrectomy on one side was performed within 72 h together with placement of a peritoneal dialysis catheter in the intensive care unit. Contralateral nephrectomy was performed after 1-2 weeks when the child was stabilized by dialysis. In 2 children, kidney transplantation has already been performed and they are doing fine. One child died after 10 months due to infection. The other children are stable on home peritoneal dialysis awaiting transplantation. CONCLUSIONS: Early bilateral nephrectomy in neonatal ARPKD is feasible, but requires distinctive care at a pediatric intensive care unit and a high amount of organizational efforts to treat these children adequately in the first few days. In our experience, the procedure is a promising approach to improve ventilation and enable dialysis. However, kidney transplantation, best from a living donor, is required within the first years of life.

[Urethral stricture after radiation therapy]. / Harnröhrenstrikturen nach Strahlentherapie.

Radiation-induced urethral stricture occurs most often due to radiation for prostate cancer. It is one of the most common side effects of radiotherapy. Stricture rates are lowest in patients undergoing external beam radiation therapy, occur more frequently in those who require brachytherapy and show highest stricture rates in patients receiving a combination of external beam radiation and brachytherapy. Strictures are mostly located at the bulbomembranous part of the urethra. Diagnostic work-up should include basic urologic work-up, ultrasound, uroflowmetric assessment, urethroscopy, retrograde urethrogram and voiding cystourethrography. Endoscopic management such as dilatation and internal urethrotomy has been proposed in short strictures. However these therapies have a high risk for recurrence. The success rate of urethroplasty is higher. Success rates of primary end-to-end anastomosis (EPA) have been reported to be 70-95 %; rates of incontinence are 7-40 %. While success rates of buccal mucosa graft urethroplasty (BMGU) range from 71-78 %, postoperative incontinence occurs in 10.5-44 %. Usually, postoperative incontinence can successfully be treated with an artificial urinary sphincter. It seems like EPA is the treatment of choice for short urethral strictures, whereas BMGU is indicated in longer, more complex strictures. Patients should be counselled with regard to length and location of strictures as well as with regard to postoperative incontinence.

Is there evidence for a close connection between side of intravesical tumor location and ipsilateral lymphatic spread in lymph node-positive bladder cancer patients at radical cystectomy? Results of the PROMETRICS 2011 database.

PURPOSE: To evaluate the possible association between bladder tumor location and the laterality of positive lymph nodes (LN) in a prospectively collected multi-institutional radical cystectomy (RC) series. METHODS: The study population included 148 node-positive bladder cancer (BC) patients undergoing RC and pelvic lymph node dissection in 2011 without neoadjuvant chemotherapy and without distant metastasis. Tumor location was classified as right, left or bilateral and compared to the laterality of positive pelvic LN. A logistic regression model was used to identify predictors of ipsilaterality of lymphatic spread. Using multivariate Cox regression analyses (median follow-up: 25 months), the effect of the laterality of positive LN on cancer-specific mortality (CSM) was estimated. RESULTS: Overall, median 18.5 LN [interquartile range (IQR), 11-27] were removed and 3 LN (IQR 1-5) were positive. There was concordance of tumor location and laterality of positive LN in 82% [95% confidence interval (CI), 76-89]. Patients with unilateral tumors (n = 78) harbored exclusively ipsilateral positive LN in 67% (95% CI 56-77). No criteria were found to predict ipsilateral positive LN in patients with unilateral tumors. CSM after 3 years in patients with ipsilateral, contralateral, and bilateral LN metastasis was 41, 67, and 100%, respectively (p = 0.042). However, no significant effect of the laterality of positive pelvic LN on CSM could be confirmed in multivariate analyses. CONCLUSIONS: Our prospective cohort showed a concordance of tumor location and laterality of LN metastasis in BC at RC without any predictive criteria and without any influence on CSM. It is debatable, whether these findings may contribute to a more individualized patient management.

[Bilateral hydronephrosis as a result of opioid-induced bowel spasm in a patient with an ileal conduit]. / Harnstauungsnieren beidseits infolge opiatinduzierter Darmspastik bei einer Patientin mit Ileumconduit.

A 47-year-old woman with spina bifida and an ileal conduit since childhood presented with left-sided flank pain, bilateral hydronephrosis and oliguria suspicious for a recurrent stenosis at the ureteral implantation site. Her history revealed a recent increase in her pain medication with opioids for treatment of neuropathic pain. After insertion of percutaneous nephrostomy on the left side and confirmation of the stenosis, open reimplantation of the ureter was already discussed with the patient. However after dose reduction of the opioid therapy hydronephrosis resolved. Thus opioid-induced bowel spasm was probably the cause for the obstruction.

[Late consequences of urethral injuries. Reconstruction options]. / Spätfolgen von Urethraverletzungen. Rekonstruktive Möglichkeiten.

BACKGROUND: Stricture excision and posterior urethroplasty is the most common procedure after posttraumatic urethral strictures. RESULTS: Re-strictures and fistulas are treated by repeat urethroplasty. Tension-free anastomosis is prerequisite for surgical success. Urinary incontinence after posttraumatic injuries is treated by an artificial urinary sphincter.

[Infra- and supradiaphragmatic urethral injuries. Acute treatment]. / Infra- und supradiaphragmale Urethraverletzungen. Akute Therapie.

BACKGROUND: Urethral injuries are often caused by pelvic fractures or blunt trauma. Drainage of the urinary bladder is the first step of therapy. RESULTS: Urethral injuries are often caused by pelvic fractures or blunt trauma. Drainage of the urinary bladder is the first step of therapy. Standard procedure is the insertion of a suprapubic stent in stable patients without concomitant open injuries in the pelvis area. Endoscopic realignment is useful in patients with pelvic fracture, vaginal, rectal, or bladder injury, who require open surgery. Delayed repair by stricture excision and open urethroplasty with end-to-end anastomosis is the standard procedure.