Application of ultrasound imaging biomarkers (HistoScanning™) improves staging reliability of prostate biopsies.

OBJECTIVE: Imaging biomarkers like HistoScanning™ augment the informative value of ultrasound. Analogue image-guidance might improve the diagnostic accuracy of prostate biopsies and reduce misclassifications in preoperative staging and grading. RESULTS: Comparison of 77 image-guided versus 88 systematic prostate biopsies revealed that incorrect staging and Gleason misclassification occurs less frequently in image-guided than in systematic prostate biopsies. Systematic prostate biopsies (4-36 cores, median 12 cores) tended to detect predominantly unilateral tumors (39% sensitivity, 90.9% specificity, 17.5% negative and 50% positive predictive values). Bilateral tumors were diagnosed more frequently by image-guided prostate biopsies (87.9% sensitivity, 72.7% specificity, 50% negative and 96.8% positive predictive values). Regarding the detection of lesions with high Gleason scores ≥ 3 + 4, systematic prostate and image-guided biopsies yielded sensitivity and specificity rates of 66.7% vs 93.5%, 86% vs 64.5%, as well as negative and positive predictive values of 71.2% vs 87%, and 83.3% vs 79.6%, respectively. Potential reason for systematic prostate biopsies missing the correct laterality and the correct Gleason score was a mismatch between the biopsy template and the respective pathological cancer localization. This supports the need for improved detection techniques such as ultrasound imaging biomarkers and image-adapted biopsies.

[Long-term results of sentinel node biopsy diagnostics in penile carcinoma : Dynamic sentinel node biopsy in cases with nonpalpable lymph nodes in the groin]. / Langzeitergebnisse der Sentinel-Lymphknotendiagnostik beim Peniskarzinom : Dynamische Sentinel-Lymphknotenbiopsie bei nicht-palpablen Leistenlymphknoten.

OBJECTIVE: Dynamic sentinel node biopsy (DSNB) has been recommended in the EAU guidelines for several years as a minimally invasive method for lymph node staging in patients with penile carcinoma and nonpalpable lymph nodes. However, due to the high methodological demands and the primarily unreliable results, this method is rarely used in Germany. The aim of this study was to establish the reliability and morbidity of this method. MATERIAL AND METHODS: The frequency of lymph node recurrent disease and complications were prospectively recorded in patients with initially nonpalpable inguinal lymph nodes and histologically negative sentinel lymph nodes. Quality criteria were the false negative rate (percentage of lymph node recurrence in negative procedures) and the morbidity rate. Inguinal regions with palpable lymph nodes and/or evidence of metastases were not considered. RESULTS: The study included 37 patients with histologically negative sentinel lymph nodes in 63 groins with nonpalpable inguinal lymph nodes. There were 21 T1(a/b) stages, 10 T2, and 6 T3 stages. Tumor differentiation was good in 4, moderate in 26, and poor in 7 patients. During a median follow-up of 52 months (range 1-131 months), we observed a bilateral lymph node recurrence in 1 patient and a conservatively managed prolonged lymphorrhea in another patient. Per inguinal region the false-negative rate was 3.2 % and the morbidity rate was 1.6 %; seen per patient the rates were both 2.7 %. CONCLUSIONS: DSNB is a reliable method of lymph node staging in patients with penile carcinoma and nonpalpable inguinal lymph nodes. The high degree of reliability in combination with the low morbidity justifies the higher methodical complexity of this method.

[Salvage lymphadenectomy in patients with prostate cancer recurrence: A review]. / Salvagelymphadenektomie beim Rezidiv eines Prostatakarzinoms : Eine Übersicht.

BACKGROUND: Salvage extended pelvic lymph node dissection (salvage ePLND) in patients with prostate cancer (PCa) biochemical recurrence is an alternative to the commonly used androgen deprivation therapy (ADT) and/or chemotherapy. Small patient number, insufficient accuracy of contemporary imaging methods for lymph node relapse diagnostics, and the lack of prospective data present limiting factors for a wider application of salvage ePLND. The purpose of this publication is to review German and European data and studies on the subject of salvage ePLND and to discuss future perspectives. MATERIALS AND METHODS: We analyzed available studies up to October 2014 from Medline with the keywords "salvage lymph node dissection prostate cancer". RESULTS: A total of 51 publications since 1984 (up to October 2014) meeting the search criteria were found. Ten of these were studies that analyzed the results of salvage ePLND. Of these 10 studies, 6 originated from German clinics. Furthermore, among these 51 publications, there were 2 clinical case reports (1 from Germany) and 3 reviews (none from Germany). CONCLUSIONS: The available data show insufficient evidence-based validity. There have been no prospective studies and just one multicenter study. However, single-center retrospective studies have shown promising results. Salvage ePLND leads to biochemical remission, freedom from clinical recurrence, and probably also to renewed response to ADT in patients with castration-resistant PCa. Multicenter prospective studies should be conducted in Germany (where most of the available studies have been performed). The selection of patients should be analyzed in order to identify clear selection criteria for salvage ePLND.

[Value of perineal HistoScanning™ template-guided prostate biopsy]. / Stellenwert der perinealen HistoScanning™-gestützten Templateprostatabiopsie.

BACKGROUND: Modern imaging modalities improve prostate diagnostics. OBJECTIVES: This study was performed to determine the outcome characteristics of biopsy procedures using the results of HistoScanning(TM) analysis (HS) for identifying prostate cancer (PCa) in patients with perineal template-guided prostate biopsy. PATIENTS AND METHODS: A total of 104 consecutive men (mean age 69 years, mean PSA 9.9 ng/ml) underwent HS prior to the extended prostate biopsy procedure. Patients received a targeted transperineal (template-assisted) as well as a targeted transrectal prostate biopsy using HS projection reports supplemented by a standardized 14-core systematic transrectal prostate biopsy (Bx). The cancer detection rate was analyzed on the sector level and HS targeted results were correlated to biopsy outcome, sensitivity, specificity, predictive accuracy, negative predictive value (NPV) and positive predictive value (PPV). RESULTS: Of 104 patients, 44 patients (42%) were found to have PCa. Histology detected atypical small acinar proliferation in 3 patients (2.9%), high-grade prostatic intraepithelial neoplasia in 16 (15.4%), and chronic active inflammation in 74 (71.1%), respectively. The detection rate for each region was significantly higher in HS-targeted biopsies compared to Bx. The detection rate per patient was not significantly different, although a smaller number of regions were biopsied with the targeted approach. The overall sensitivity, specificity, predictive accuracy, NPV, and PPV on the sector level were 37.2, 85.6, 78.6, 88.7 and 30.8%, respectively. CONCLUSION: The use of HS analysis results in a higher detection rate of prostate cancer compared to common transrectal ultrasonography (TRUS)-guided Bx. This technique increases the informative value of TRUS imaging and improves the diagnostic impact at least in the targeted biopsy setting.

[Urogynecology II: urinary incontinence in men and women: surgical treatment of urinary incontinence and prolapse]. / Urogynäkologie II: Harninkontinenz bei Mann und Frau : Chirurgische Therapie der Harninkontinenz und des Prolapses.

Numerous surgical procedures are available for the treatment of stress urinary incontinence in women and men. On a par with classical therapy options (e.g. colposuspension and artificial sphincter prosthesis) suburethral tape procedures have become established as the minimally invasive standard of care. Regarding comorbidities and recurrent urinary incontinence, therapeutic procedures should be modified on an individual basis. It is crucial to involve patients in therapeutic decision-making and counseling should be given with respect to all conservative and operative alternatives.

[Urinary incontinence in men and women. Diagnostics and conservative therapy]. / Harninkontinenz bei Frau und Mann. Diagnostik und Konservative Therapie.

Urinary incontinence can affect men and women to the same degree. A differentiation is made between stress incontinence (i.e. urine discharge as a result of physical activities, sneezing or coughing), urge incontinence (i.e. strong urge to void with involuntary discharge of urine), mixed urinary incontinence and special forms. While men and women share the pathophysiology of urge-associated urinary incontinence, the multifactorial female urinary stress incontinence is in contrast to the stress incontinence in men which is almost exclusively caused by prostatectomy (postprostatectomy). The basic diagnostic procedure for urinary incontinence is largely non-invasive. Special diagnostic procedures are reserved for recurrences and preparation for operative measures. Therapy is oriented to the degree of suffering and patient compliance and incorporates conservative measures as first line therapy (e.g. lifestyle changes, bladder and continence training). Duloxetin is approved for the medicinal therapy of female urinary stress incontinence. The treatment of urge-associated urinary incontinence is primarily with anticholinergic agents. Alternatively, procedures for neuromodulation, a beta mimetic or injection therapy with botulinum toxin can be used in the future.

[Sentinel lymph node biopsy for penile carcinoma : Assessment of reliability]. / Sentinel-Lymphknotenbiopsie beim Peniskarzinom : Überprüfung der Zuverlässigkeit.

BACKGROUND: The European Association of Urologists recommends dynamic sentinel node biopsy (DSNB) as the first choice diagnostic approach for lymph node staging of non-palpable inguinal lymph nodes in penile carcinoma. The aim of this study was to assess the reliability of minimally invasive inguinal DSNB. MATERIAL AND METHODS: Between 2004 and 2012 DSNB was used in all patients with invasive penile carcinoma and non-palpable inguinal lymph nodes. For assessment of reliability the rate of false negative results was determined and complications were documented. The results were analyzed prospectively. RESULTS: In the study period DSNB was performed in a total of 29 patients and it was possible to prove lymph node metastasis in 2 patients with 1 patient who developed lymph node metastasis after a negative DSNB. Thus the false negative rate was 3.70 %. A morbidity rate of 3.45 % was also observed. CONCLUSION: Sentinel lymph node biopsy is a reliable diagnostic method. The sophisticated requirements both methodologically and logistically suggest that this procedure should only be performed in specialized centres.

[Prolapse surgery: vaginal mesh or sacropexy]. / Deszensuschirurgie : Auffangnetze oder Sakropexie?

The systematic assessment of common therapy concepts for female genital prolapse has led to a better understanding of the functional and anatomical connections and given proof of the lasting effectiveness of traditional surgery. Besides the defined evidence-based therapy strategies in vaginal prolapse repair, vaginal meshes are being used with increasing frequency. The lack of reliable therapy recommendations for these methods sounds us a note of caution in their application and underlines the necessity of standardised performance in experienced departments.

[Erectile dysfunction after radical prostatectomy : patient information, contact persons, postoperative proerectile therapy]. / Erektile Dysfunktion nach radikaler Prostatektomie : Aufklärung, Ansprechpartner, postoperative proerektile Therapie.

BACKGROUND: Postoperative erectile dysfunction (ED) is one of the potential after-effects of radical prostatectomy. The aim of this study was to learn which caregivers inform the patients prior to the intervention about the risk of ED, which individuals the patients discuss this issue with, and whether the patients preoperatively consider use of a PDE5 inhibitor for proerectile therapy after the operation. METHODS: Using the IIEF-5 questionnaire, the preoperative erectile function of 110 patients was evaluated after the hospital admission interview. The patients were asked who had informed them about the risk of postoperative ED. They were also asked in whom they had confided to discuss this issue and whether they were prepared to undergo postoperative proerectile therapy with a PDE5 inhibitor. The patients were subsequently assigned to one of two groups: group I, consisting of those with a preoperative IIEF score > or = 21, or group II, those with a preoperative IIEF score <21. RESULTS: The answers given by groups I and II did not differ significantly. The median patient age was the same, 68, in both groups. In addition to being informed about postoperative ED by the hospital doctor on admission (100%), the patients were informed about this by the following individuals (results for group II in parentheses): board-certified urologist, 81.8% (74%); general practitioner (GP), 27.3%; partner, 12.1% (11.7%); self-help groups, 0% (2.6%); and friends, 3% (6.5%). Patients also discussed the risk of postoperative ED with the following individuals (results for group II in parentheses): local urologist, 66.7% (63.4%); partner, 45.5% (42.9%); hospital doctor, 39.4% (42.9%); GP, 21.2% (23.4%); friends, 9.1% (14.3); or no one, 3% (5.2%). Regarding whether patients were willing to undergo postoperative therapy using a PDE5 inhibitor, 36.4% in group I and 32.5% in group II said yes, 12.1% in group I and 11.7% in group II said no, and 51.5% in group I and 55.8% in group II were undecided. CONCLUSION: Irrespective of the patient's erectile status, the hospital doctor and the local urologist informed the patients about the risk of postoperative ED. Satisfactory information delivered by at least two people occurred in over 70% of all cases. The most frequent confidant of the patient for discussing this issue was his local urologist. Fewer than 50% of the patients discussed this topic with their partners. Possible reasons for underestimating the importance of sexual function could be the frequent taboo status of sexuality as a discussion topic in relationships, as well as preoperative distress. These circumstances should be taken into account by offering sufficient information, including that on the availability of postoperative proerectile therapy, for both the patient and his partner as early as possible, i.e., at the stage of choosing a treatment option.

[Vaginal descensus and prolapse. Which operative technique?]. / Deszensus und Prolaps der Vagina. Welches Operationsverfahren?

Despite the high prevalence of genital prolapse, there are only few studies so far fulfilling the strict criteria of evidence-oriented data acquisition. On the one hand, this complicates the definition of reliable therapy recommendations, on the other hand, it sounds a note of caution in the application of therapy approaches which are new and have not yet been evaluated adequately.The systematic assessment of common therapy concepts for female genital prolapse and its accompanying pathologies has led to a better understanding of the functional and anatomical background within the last few years. Thus, any invasive anatomical correction should strictly be used with the aim of functional improvement and with evidence of persisting effectivity. Under this premise, traditional methods of vaginal and abdominal prolapse repair still come into use. The choice of the operative technique arises from carefully differentiated, interdisciplinary diagnostics and surgery should be performed in experienced centers.

[Functional results after temporary continuous drainage of the hypocontractile bladder. The potential rehabilitation of the detrusor]. / Funktionelle Ergebnisse nach temporärer Dauerableitung der hypokontraktilen Blase. Zur Rehabilitationsfähigkeit des Detrusors.

BACKGROUND: Impaired bladder emptying is a common problem in older people and a challenging task in treatment. Conservative and medical treatment options have shown beneficial effects on micturition; however, in a substantial number of patients the effectiveness of these therapies is disappointing. In the end the decompensated bladder needs indwelling catheterisation. To study the effects on the detrusor function, we analysed the urodynamic data of 31 patients during long-term bladder drainage retrospectively. PATIENTS AND METHODS: All 17 female and 14 male patients showed impaired detrusor contractility, enlarged bladder capacity, decreased sensitivity and a high post-void residual urine volume (PVR). After exclusion of an acute pathology, the patients were treated continuously with a suprapubic catheter for an average of 13.1 weeks. By urodynamic measurements before and after the drainage period, we analysed the filling parameters, pressure-flow patterns, PVR and detrusor contractility. RESULTS: At the end of the drainage period, significant changes in the detrusor function were obvious. Compared with the pre-treatment situation, the bladder volume at first desire to void decreased from 306.92 ml to 281.7 ml and the maximum bladder capacity from 691.8 ml to 496.8 ml, respectively. The compliance of the detrusor muscle diminished in the same period of time from 65.6 ml/cmH2O to 51.8 ml/cmH2O. The PVR dropped by 227.2 ml in average. The maximum flow rate was 9.4 ml/s, and the maximum detrusor pressure increased slightly up to 23.6 cmH2O. CONCLUSION: The continuous drainage of the bladder results in significant changes in the motoric as well as sensoric detrusor function. The reduced bladder capacity and the decreased PVR might be indications of a regenerating process of the detrusor. The long-term drainage of the bladder shows beneficial and therefore therapeutic effects. It still remains to be investigated on a functional as well as structural basis to what extent age, gender and pathogenesis influences the rehabilitation of the detrusor.

[30 Years of sentinel lymph node diagnostic in penile carcinoma: development of a diagnostic procedure and current results]. / 30 Jahre Sentinel-Lymphknotendiagnostik beim Peniskarzinom : Evolution eines diagnostischen Verfahrens und eigene aktuelle Ergebnisse.

Cabanas, working 30 years ago, was the first to use the term "sentinel lymph node" in urology. His definition of the sentinel lymph node was based on typical anatomical patterns and therefore could not do justice to any individual variability in lymphatic drainage. This meant that application of the technique yielded high false-negative rates, and because of this it was largely abandoned. Dynamic visualization of lymphatic drainage by blue dye in melanoma patients resulted in a renaissance of the sentinel node concept in penile cancer in the mid-1990s. With constant improvements and standardization of the technique it proved possible to reduce the incidence of false-negative results from the initial 22% to 4.8%. This technique requires that specialists in urology, pathology, and nuclear medicine collaborate closely, and high standards are also essential in quality control.

[Stone management in children]. / Steintherapie im Kindesalter.

The extracorporeal shock-wave lithotripsy (ESWL) is still the treatment of choice for almost all stones in children. But with advances in instrumentation, endourological procedures are being performed more frequently in younger patients. Especially in the treatment of distal ureteral stones retrograde ureteroscopy now competes with ESWL. Finally, the recent literature supports percutaneous nephrolithotomy as a safe and effective treatment option for large renal calculi and staghorn calculi. This gives the clinician the opportunity to choose from a wide range of treatment alternatives. Proper treatment planning, technique and availability of appropriate instrumentation are important to achieve an optimal outcome.

[Functional outcome after laser vaporisation of the prostate with the KTP laser]. / Funktionelle Ergebnisse nach Laservaporisation der Prostata mit dem KTP-Laser.

BACKGROUND: Treatment for bladder outlet obstruction (BOO) caused by benign prostatic hyperplasia (BPH) impairs the quality of life. The potassium tintanyl phosphate (KTP) vaporisation of the prostate offers promising modalities in treatment of BOO. We prospectively determined the impact of KTP-lasertherapy on voiding function, quality of life and sexual function. PATIENTS AND METHODS: So far a total of n=123 patients complaining of symptomatic BPH were treated with an 80 watt Laser. N= 40 of them agreed to participate in the study and were evaluated prospectively. Preoperative pressure-flow-studies verified significant bladder outlet obstruction in all cases. Disease specific quality of life and sexual function were assessed using the International Prostate Symptom Score (IPSS) and International Inventory of Erectile Function (IIEF). Three months after treatment follow-up video-urodynamics were carried out to determine changements in pressure flow and bladder function. RESULTS: All patients showed significant improvement after a hospital stay of 4,9 days. The maximum flow rate increased from 9,1 ml/sec preoperatively to 20,2 ml/sec and the amount of residual urine decreased from 98 ml preoperatively to 17 ml immediately after removal of the catheter. Urodynamics after the follow up period showed that the maximum urinary flow improved from 9.7 ml/s preoperatively to 17,6 ml/s and the volume of residual urine decreased from a median of 127.5 ml preoperatively to 45 ml postoperatively. The IPSS and IIEF decreased from a median of 20,4 preoperatively to 8,16 and from a median of 14 preoperatively to 12,7 respectively. The pressure-flow study verified the desobstruction and showed a decline in detrusor pressure at maximum flow from 76,66 cm H2O to 33,79 cm H2O. The urethral opening pressure sank from 75.86 cm H2O preoperatively to 37,51 cm H2O postoperatively. CONCLUSION: The potassium tintanyl phosphate (KTP) vaporisation of the prostate is a promising new method in the treatment of benign prostatic hyperplasia as shown by the data. Beside its low perioperative and postoperative morbidity due to a high hemostatic property it offers a good tissue debulking effect.