A randomized trial regarding antimicrobial prophylaxis (AMP) in transurethral resection of bladder tumor (TURB).

PURPOSE: To determine whether omitting antimicrobial prophylaxis (AMP) in TURB is safe in patients undergoing TURB without an indwelling pre-operative catheter/nephrostomy/DJ and a negative pre-operative urinary culture. MATERIALS AND METHODS: A multi-centered randomized controlled trial (RCT) from 17-09-2017 to 31-12-2019 in 5 hospitals. Patients with a pre-operative indwelling catheter/DJ-stent or nephrostomy and a positive pre-operative urinary culture (> 104 uropathogens/mL) were excluded. Post-operative fever was defined as body temperature ≥ 38.3 °C. A non-inferiority design with a 6% noninferiority margin and null hypothesis (H0) that the infection risk is at least 6% higher in the experimental (E) than in the control (C) group; H0: C (AMP-group) - E (no AMP-group) ≥ Δ (6% noninferiority margin). A multivariable, logistic regression was performed for AMP and post-TURB fever with covariates: tumor size and (clot-) retention. The R Project® for statistical computing was used for statistical analysis and a p value of 0.05 was considered as statistically significant. RESULTS: 459 Patients were included and 202/459 (44.1%) received AMP vs 257/459 (55.9%) without AMP. Fever occurred in 6/202 [2.9%; 95% CI (1.2-6.6%)] patients with AMP vs 8/257 [3.1%; 95% CI (1.5%-6.1%)] without AMP (p = 0.44). Multivariable, logistic regression showed no significant harm in omitting AMP when controlled for (clot-)retention and tumor size (p = 0.85) and an adjusted risk difference in developing post-TURB fever of 0.0016; 95% CI [- 0.029; 0.032]. CONCLUSION: Our data suggest the safety of omitting AMP in patients undergoing TURB without an indwelling, pre-operative catheter/nephrostomy/DJ and a negative pre-operative urinary culture.

Antimicrobial Prophylaxis in Transurethral Resection of the Prostate: Results of a Randomized Trial.

PURPOSE: We sought to determine whether omitting antimicrobial prophylaxis is safe in patients undergoing transurethral resection of the prostate without preoperative pyuria and a preoperative catheter. MATERIALS AND METHODS: We conducted a multicenter randomized controlled trial from September 17, 2017 until December 31, 2019 in 5 hospitals. Patients with pyuria (>100 white blood cells/ml) and a preoperative indwelling catheter were excluded. Postoperative fever was defined as a body temperature ≥38.3C. A noninferiority design was used with a 6% noninferiority margin and null hypothesis (H0) that the infection risk is at least 6% higher in the experimental (E) than in the control (C) group; H0: C (antimicrobial prophylaxis group) - E (no antimicrobial prophylaxis group) ≥ Δ (6% noninferiority margin). A multivariable, logistic regression was performed regarding posttransurethral resection of the prostate fever and antimicrobial prophylaxis with co-variates: (clot-)retention and operating time. The R Project® for statistical computing was used and a p value of 0.05 was considered as statistically significant. RESULTS: Of the patients 474 were included for multivariable analysis and 211/474 (44.5%) received antimicrobial prophylaxis vs 263/474 (55.5%) patients without antimicrobial prophylaxis. Antibiotics were fluoroquinolones in 140/211 (66.4%), cephazolin in 58/211 (27.5%) and amikacin in 13/211 (6.2%) patients. Fever occurred in 9/211 (4.4%) patients with antimicrobial prophylaxis vs 13/263 (4.9%) without antimicrobial prophylaxis (p=0.8, risk difference 0.006 [95% CI -0.003-0.06, relative risk 1.16]). We were able to exclude a meaningful increase in harm associated with omitting antimicrobial prophylaxis (p=0.4; adjusted risk difference 0.016 [95% CI -0.02-0.05]). CONCLUSIONS: Our data demonstrate the safety of omitting antimicrobial prophylaxis in patients undergoing transurethral resection of the prostate without preoperative pyuria and a preoperative indwelling catheter.

Ureteral ectopy in the seminal vesicle associated with cyst formation and renal dysplasia: contribution of 3D-MRI.

A case of a congenital anomaly of the urinary tract in a 25-year-old Caucasian male is presented. Preoperative and pathologic findings demonstrated an ectopic ureter which terminated in a seminal vesicle cyst. Both structures formed an abortive common duct at the bladder base. The ipsilateral kidney was dysplastic. Findings on voiding cytourethrography, spiral CT, and MRI are discussed and correlated with pathologic findings. The authors suggest that MRI, especially with the use of 3D sequences, is the examination of choice in the evaluation of a complex congenital urogenital anomaly as presented.

[The role of radical prostatectomy in cT3 prostate carcinoma]. / Die Rolle der radikalen Prostatektomie beim cT3-Prostatakarzinom.

A clinical cT3 prostate cancer can mean so many different tumors, that no single approach can actually be proposed. Radical prostatectomy has become standard treatment for T1/T2 tumors, but the surgical treatment for the clinical T3 prostate cancer has always been and remains controversial, although some urologists felt that radical prostatectomy remained a treatment option for T3 prostatic cancer when poor prognosis patients were excluded. The clinical staging of locally confined or locally advanced prostate cancer is not reliable. More than 70% of the clinically T2-tumors are pT3. On the others hand clinically T3-tumors are sometimes overestimated and about 20% of the clinical T3 cancers were shown to be pT2.--At the Department of Urology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Belgium--158 patients had radical prostatectomy for clinical stage T3N0M0 prostate cancer. 110 patients were surgically treated only. 30 patients had adjuvant hormone-therapy and were considered to be progressive at 1 month because PSA follow-up is unreliable. 18 other patients were irradiated postoperatively. PSA-free survival rate exceeds 70% at 24 months and the 5 years estimated PSA-free survival is more than 60%. Summarizing radical prostatectomy appears to be a justified treatment modality in pT3-prostate cancer, if PSA is < 10 ng/ml.

Magnetic resonance imaging in the assessment of urologic disease: an all-in-one approach.

The aim of this study was to evaluate an "all-in-one" MR procedure to examine the kidneys, the renal vascular supply and renal perfusion, and the urinary tract. In 64 patients (58 with urologic disease and 6 healthy volunteers), MR was performed including: (a) T1- and T2-weighted imaging; (b) 3D contrast-enhanced MR angiography (MRA), including the renal arteries, renal veins, as well as renal perfusion; and (c) 3D contrast-enhanced MR urography (MRU) in the coronal and sagittal plane. For the latter, low- and high-resolution images were compared. Prior to gadolinium injection, 0.1 mg/kg body weight of furosemide was administered intravenously. The results were compared with correlative imaging modalities (ultrasonography, intravenous urography, CT), ureterorenoscopy and/or surgical-pathologic findings. Visualization of the renal parenchyma, the vascular supply, and the collecting system was adequate in all cases, both in nondilated and in dilated systems and irrespective of the renal function. One infiltrating urothelial cancer was missed; there was one false-positive urothelial malignancy. Different MR techniques can be combined to establish an all-in-one imaging modality in the assessment of diseases which affect the kidneys and urinary tracts. Continuous refinement of the applied MR techniques and further improvements in spatial resolution is needed to expand the actual imaging possibilities and to create new tracts and challenges in the MR evaluation of urologic disease.

Radical prostatectomy can provide a cure for well-selected clinical stage T3 prostate cancer.

OBJECTIVE: Radical prostatectomy is commonly believed not to achieve the eradication of locally advanced disease. This retrospective study aimed to elucidate the role of radical prostatectomy in this condition. METHODS: A retrospective study of 158 patients surgically treated for clinical stage T3N0M0 prostate cancer was undertaken. Thirty patients had postoperative hormonal treatment, rendering prostate-specific antigen (PSA) follow-up unreliable, and were considered to be progressive at 1 month. Eighteen other patients received postoperative radiotherapy. One hundred and ten patients had radical prostatectomy only. PSA-relapse-free survival was analyzed. The mean follow-up time was 30 months. RESULTS: Seventy-nine percent of the resected specimens were pathologically T3 (pT3), and about 25% were pT3c. Thirteen percent were pT2 and 8% were pT4. Ninety-five specimens (60%) had positive surgical margins. There was poor accordance between the biopsy Gleason score and that of the specimen. A multivariate analysis showed that seminal vesicle and nodal invasion, margin status and a PSA level above 10 ng/ml were independent prognostic factors. In 47 cT3a patients with PSA <10 ng/ml, the PSA-free survival rate exceeded 70% at 24 months and the 5-year estimated PSA-free survival rate was more than 60%. CONCLUSIONS: Radical prostatectomy has a place in the treatment of clinical stage T3 prostate cancer patients with a PSA value lower than 10 ng/ml. There is a need to definitively rule out nodal or seminal vesicle invasion in order to select those patients that can benefit from surgery.

Carcinoma of the kidney, testis, and rare urologic malignancies.

The purpose of this symposium was to provide a forum for discussion on current information on the etiology and diagnosis of, and therapy for, tumors of the kidney, testis, and several uncommon malignancies of the genitourinary tract. The most recent contributions in epidemiology and molecular genetics were discussed with specific reference to their importance for clinical practice. Contemporary treatment approaches with the emphasis on multidisciplinary patient management of tumors commonly seen in the clinic as well as those that are only rarely diagnosed by urooncologists were presented. Major stress was given to the management optimization as it pertains to short- and long-term quality of life issues of patients treated for these tumors. Methods to reduce treatment toxicity including carcinogenic potential of chemotherapy, radiotherapy, or their combination were found to be of nearly equal importance to patient survival. Symposium participants reached consensus on a number of important points: 1) The management of patients with several malignancies discussed requires the presence of a multidisciplinary team of specialist who are interested in diagnosis and treatment of genitourinary tumors; 2) Patients managed in such an environment are expected to have optimal survival and the best possible quality of life; 3) Real advances in the management of patients can be best obtained through well-designed prospective clinical trials; and 4) There is a need for timely introduction of relevant advances in epidemiology and molecular genetics to clinics.

[Preliminary experiences with the use of the Holmium-YAG laser in the treatment of soft tissues and of cystine calculi in children]. / Premières expériences avec l'utilisation du laser Holmium-YAG dans le traitement des tissus mous et des calculs de cystine chez l'enfant.

INTRODUCTION: Experience of the use of the Holmium: Yttrium-Aluminium-Garnet (Ho:YAG) laser in children has been limited. However, the Ho:YAG laser has been in clinical use in urology for several years but has mainly been used for the treatment of renal stones and benign prostatic hyperplasia. Due to its unique combination of vaporization and coagulation, the Ho:YAG laser allows a precise cutting action. The depth of penetration in water and tissue is limited to < 0.5 mm and therefore provides a safety margin. The Ho:YAG laser can be used in children, as the energy can be delivered via fibers that range from 200 to 1000 mu in diameter. MATERIALS AND METHODS: We used the Ho:YAG laser in 5 children (2-15 years): one child (2 years) with bladder exstrophy had a urethral stricture after bladder neck reconstruction, two children (6 years and 14 years) had ureteropelvic junction (UPJ) stenosis and refused open surgery and two children (5 years and 15 years) suffered from cystine stones (ESWL failed). The urethral stricture was incised in a retrograde fashion. We performed an antegrade incision of the UPJ with the Ho:YAG laser in the 6-year-old child and a retrograde incision in the 14-year-old child. We removed the stones in antegrade fashion in the 5-year-old child and in retrograde fashion in the 15-year-old child. RESULTS: All children now have more than 12 month's follow-up. There were no immediate or late complications. The boy with urethral stricture remained free of recurrence, the boy with UPJ stenosis obtained improved drainage on the excretory renogram and the two children with cystine stones remained stonefree. CONCLUSION: We have shown that the safety and efficacy of the Ho:YAG laser is also reproducible in urologic pathology in children. In addition, due to its vaporizing quality, the Ho:YAG laser is more effective in the treatment of cystine stones and allows minimaly invasive treatment in children.

Mitomycin C for metastatic prostate cancer: final analysis of a randomized trial.

BACKGROUND: Almost all patients that undergo hormonal manipulation for metastatic prostate cancer will ultimately progress because of hormone resistance. Therefore we assessed the effect of early addition of intravenous Mitomycin C to orchiectomy in patients with newly diagnosed metastatic prostate cancer. PATIENTS AND METHODS: 178 patients with histologically proven and previously untreated metastatic prostate cancer were included in a prospective, randomized multicenter trial. Randomization was done centrally between orchiectomy alone and orchiectomy with Mitomycin C. 148 patients were evaluable. RESULTS: At the final analysis 139 patients have deceased. The remaining 9 patients are still alive, but all present progression. There was no statistically significant difference in the real time to progression, or in the estimated cancer related and overall survival between both groups. Mean time to progression was 29 months in group 1 (orchiectomy alone), and 26 months in group 2 (orchiectomy and Mitomycin C) (p = 0.64). Mean time to cancer related death was 32 months and mean overall survival was 31 months in both groups. CONCLUSIONS: Mitomycin C has no beneficial effect when used in conjunction to orchiectomy in patients with newly diagnosed metastatic prostate cancer.

A cystine lower pole renal calculus treated with holmium: YAG laser using a flexible 9,5F transurethral ureteroscope.

We report a case of a 1.5 cm cystine staghorn calculus of the right lower pole in a 32 year female known cystinuric patient. With a 200 microns Holmium laser probe through a 9,5 F flexible ureteroscope the calculus was fragmented in small particles. An internal ureteral stent was inserted at the end of the procedure. All but one small residual fragments were evacuated spontaneously after removal of the stent. This case shows that flexible ureteroscopy combined with the Holmium laser is a safe and efficient procedure to treat medium size renal cystine calculi. It can be repeated in case of recurrence with minimal trauma to the urologic tract.

Acute obstruction of the renal collecting system: the intrarenal resistive index is a useful yet time-dependent parameter for diagnosis.

The aim of this study was to determine whether the intrarenal resistive index (RI) can be used for the diagnosis of acute obstruction in patients with renal colic and to determine whether the index is time-related. Seventy patients referred to the Emergency Department with acute renal colic and without known associated renal disease underwent duplex Doppler ultrasonography to determine the intrarenal RI at the symptomatic and asymptomatic side. The age range of the patients was 18-72 years. An RI greater than 0.68 and/or an interrenal difference in RI greater than 0.06 and/or an increase in RI of more than 11% compared with the normal side proved reliable cut-off values to diagnose acute renal obstruction. In addition, time dependency of the increase in RI was noted. No significant differences were observed within the first 6 h after the onset of symptoms. From 6 to 48 h, however, the mean RI in the affected kidney (0.70 +/- 0.06; mean +/- SD) was significantly different from that in the normal kidney (0.59 +/- 0.04) (P < 0.001). In the same period the mean difference in RI was 0.08-0.13 (P < 0.001). After 48 h the sensitivity of RI dropped substantially. It is concluded that renal duplex Doppler ultrasonography is useful for diagnosing acute renal obstruction between 6 and 48 h after the onset of symptoms.

Microscopic vascular invasion is the most relevant prognosticator after radical nephrectomy for clinically nonmetastatic renal cell carcinoma.

PURPOSE: Although many factors have been considered to predict the outcome after radical nephrectomy, renal cell carcinoma continues to behave unpredictably. In a retrospective study the correlation between microvascular tumor invasion and disease-free survival after surgery for renal cell carcinoma was analyzed. MATERIALS AND METHODS: Between 1980 and 1993, 180 patients (mean age 60 years) were followed for a mean of 52 months after radical or partial nephrectomy for clinically localized renal cell carcinoma. The relevance of microscopic vascular invasion was compared to classical tumor staging, grade and tumor diameter. RESULTS: Microscopic vascular invasion was found in 51 patients (28.3%), including 20 (39.2%) with progression (mean interval to progression 72 months). Of 129 patients with no pathological evidence of microscopic vascular invasion only 8 (6.2%) showed progression at a mean interval of more than 160 months. The difference in disease-free survival as a function of microvascular invasion was statistically highly significant (log rank p < 0.00001) and on multivariate analysis this parameter was by far the most relevant predictor of progression. CONCLUSIONS: In patients who underwent radical nephrectomy for clinically nonmetastatic renal cell carcinoma with microvascular invasion but without lymph node involvement or macroscopic vascular invasion the chance of disease progression is estimated at 45% within 1 year. Microvascular invasion is the single most relevant prognosticator after presumed curative radical nephrectomy for renal cell carcinoma.

Adenocarcinoma of the prostate: innovations in management.

Adenocarcinoma of the prostate (CaP) in the Western world has become the most common noncutaneous human tumor. CaP is also the second most important cause of cancer deaths among the male population in the United States. Major progress was made in the past decade in better understanding this disease process, as well as in improved diagnostic accuracy. This improved diagnostic accuracy was due to wide application of prostate-specific antigen (PSA), use of transrectal ultrasound (TRUS), and greater awareness among clinicians of CaP. The use of PSA in clinical practice has resulted in a sharp increase in the number of patients diagnosed with capsule-confined tumors. The optimal treatment for capsule-confined CaP is in the process of being defined. Radical prostatectomy in the United States is currently the most commonly applied treatment for younger patients. Excellent treatment results with a 10-year actuarial survival > 80% are readily obtainable in properly selected patients. Nerve-sparing procedures helped reduce the high incidence of impotence that occurs in patients after radical retropubic prostatectomy. Radiotherapy remains the other curative treatment method in the management of CaP patients, with long-term survival rates similar to those reported in surgical series. Due to the problem of frequent preoperative tumor understaging, a routine use of postoperative irradiation to the prostatic fossa produces an excellent (> 95%) incidence of local tumor control. Management of patients with metastatic disease has undergone a considerable evolution with the development of modern hormonal management and treatment with strontium-89 to control intractable bone pain. Newer treatment methods such as hyperthermia are currently being investigated. Major efforts are directed toward the reduction of short- and long-term treatment toxicity associated with surgery, radiotherapy, and hormonal management, thus improving patient quality of life.

Treatment of metastatic carcinoma of the prostate.

Disseminated carcinoma of the prostate (CaP) is a common manifestation of this disease. Metastatic CaP in the United States is seen in about 45,000 patients each year at diagnosis. At least the same number of patients who have had prior definitive treatment with surgery or radiotherapy develop evidence of metastatic disease. Hormonal management is the most important and well established treatment for patients with prostatic metastases. Orchiectomy remains the most efficient and most cost effective therapy in a rapid ablation of testicular androgens. Due to a well known psychological reaction to castration which is seen in many patients, diethylstilbestrol (DES) is a good alternative and cost effective therapy. The mode of action of DES is to suppress LH production and to slowly, indirectly, decrease serum testosterone level. In recent years, total androgen blockade (TAB) has become a widely accepted treatment option. This treatment has been shown in several clinical trials to be effective and well tolerated by the patients. A major problem with a routine use of TAB is a relatively high cost of this therapy. In a European prospective randomized trial, goserelin acetate-flutamide combination significantly increased time to progression when compared with orchiectomy alone. Patients with localized and symptomatic metastases are best treated with radiotherapy. Those with multiple sites of involvement are best treated with strontium-89 which results in a good palliation in a majority of patients. Nearly all hormonally treated patients, with metastatic CaP, eventually show tumor progression. Presently available chemotherapy is of a low effectiveness and should not be used for these patients outside of controlled clinical trials. Current research is directed to identify effective therapy for hormone refractory patients. Immunotherapy and gene therapy may be useful future therapeutic options.

Non-Hodgkin's lymphoma of the prostate in a young male.

A case of non-Hodgkin's lymphoma (NHL) involving the prostate and the urinary bladder in a 24-year-old male is reported. Although none of the currently available imaging modalities is specific for the diagnosis of NHL of the prostate, this diagnosis must be considered because of its amenability to treatment. The heterogeneity of the mass at CT and MRI might be suggestive of high-grade NHL. The patient was treated with intensive combination chemotherapy.

The new generation Siemens Multiline lithotripter tube "M": early results in ureteral calculi.

The Siemens electromagnetic Lithostar tube "C" and the new multiline tube "M" lithotripters were compared for the in situ treatment of ureteral calculi. A series of 248 patients with a calcium oxalate ureteral stone (proven by stone analysis) more than 4 mm in diameter were treated between December 1994 and September 1995 with the tube M Multiline lithotripter. The results were compared with those of 462 patients treated in prior years with tube C. High energy levels were obtained without sedation in 11% of patients with tube C and in 61% with tube M. The proportion of patients needing additional analgetics was 11% and 6%, respectively. The percentages of patients reporting no pain at all were 7 and 77. In proximal calculi, stone-free status was achieved in 63 of 79 patients (80%) with tube C and in 82 of 91 patients (90%) with tube M (p = 0.057). In distal calculi, stone-free status was achieved in 124 of 173 patients (72%) with tube C and in 134 of 157 patients (85%) with tube M (p = 0.0027). The evacuation rate for distal ureteral stones was significantly higher with tube M, which implies that the new shock head can enable the operator to apply higher energy without sedation because of the better tolerance.

Serum tissue polypeptide antigen (TPA) as tumor marker for bladder cancer.

Tissue polypeptide antigen is a differentiation and proliferation marker of non-squamous epithelium and derived neoplasms. No reliable tumor markers are available for bladder cancer. The value of tissue polypeptide antigen was therefore prospectively investigated. The serum tissue polypeptide antigen samples were obtained from 144 newly diagnosed transitional cell carcinoma patients and from 92 patients that were followed after treatment. The normal cut off value was defined at 95 units per liter. Nearly all TaT1 patients had normal TPA values, and 80% of the muscle invasive cancers had normal TPA levels. In those patients where TPA was elevated before treatment its monitoring proved to be a reliable predictor of tumor progression. Tissue polypeptide antigen is a useful marker not for the early detection of bladder cancer but for the monitoring of the efficacy of a treatment.

The case against fine-needle aspiration cytology for small solid kidney tumors.

Conservative renal cell cancer surgery in elective conditions can be applied if the tumor is solitary and well delineated on the CT scan and easily resectable within a rim of healthy parenchyma. A number of solid tumors will prove not to be malignant on definite pathological examination. The radiological preoperative differential diagnosis of a small renal mass is not always obvious. The efficacy of fine-needle aspiration cytology in recognizing the pathology of the tumor before surgery is limited and major complications have been reported. Moreover, it can render a conservative surgical procedure less safe. Thus fineneedle aspiration cytology is not recommended if conservative surgery is planned, unless renal involvement by metastasis or lymphoma is suspected.