[Prevention, early diagnosis and treatment of chemoextravasation. Practical management in the uro-oncological practice]. / Prävention, Früherkennung und Behandlung von Zytostatikaparavasaten. Praktisches Management in der uroonkologischen Praxis.

Extravasation of chemotherapeutic agents is a rare (1-6%) but potentially severe iatrogenic complication of systemic therapy. Depending on the cytotoxic agent, tissue damage and necrosis may occur, followed by a delay in administration of chemotherapy, prolonged hospitalization, impaired function, and the need for tissue excision. Therefore, optimal placement of the intravenous catheter is absolutely necessary to reduce the risk of extravasation. The aim of this report is to give urologists a practical and useful guide on how to prevent, diagnose, and treat this complication.

[Testosterone replacement therapy and prostate cancer. The current position 67 years after the Huggins myth]. / Testosteronsubstitution und Prostatakarzinom. Eine Standortbestimmung 67 Jahre nach dem Huggins-Mythos.

Hypogonadism is highly prevalent in the elderly and in men with prostate cancer. Symptoms of hypogonadism, such as depression, lack of libido, and decreased bone mineral density, can significantly impair quality of life. In addition, testosterone plays an important role in erectile preservation and in growth and function of the cavernosal and penile nerves. There are compelling data showing that testosterone replacement therapy (TRT) does not increase the risk of prostate cancer. The literature (four published studies) concerning men treated with TRT after definitive therapy for prostate cancer reports only one biochemical recurrence. Based on these data, physicians cannot really justify withholding TRT from symptomatic patients after they have been successful treated for prostate cancer. This review gives the practising urologist an overview of the latest literature and useful advice on this controversial topic.

Transrectal ultrasound as diagnostic tool for the detection of local recurrence following cystectomy and urinary diversion.

OBJECTIVE: Routine follow-up after cystectomy for bladder cancer detect patients with local recurrence late in the course of disease. We set out to determine the value of transrectal ultrasound (TRUS) as diagnostic tool to diagnose local failure. PATIENTS AND METHODS: Between 1986 and 2003, radical cystectomy for bladder cancer with orthotopic diversion was performed in 642 male patients. We identified all patients that simultaneously had transabdominal ultrasound, digital rectal examination, TRUS and CT/MRI of the pelvis at the diagnosis of local recurrence. RESULTS: Mean follow-up was 59.4 months. 83/642 patients (13%) had local failure of bladder cancer during follow-up. In 48/642 patients (7.5%) the local recurrence was the first site of recurrence. 35/642 patients (5.5%) developed local failure with concomitant distant disease. 31/83 patients met the inclusion criteria. The median time between cystectomy and diagnosis of local recurrence was 13 months (2-51 months). Routine follow-up detected local recurrence in 1 asymptomatic patient. 25/31, 3/31 and 2/31 patients had pain in the lower extremities/pelvis, hematuria and urinary retention, respectively. Digital rectal examination, transabdominal ultrasound, TRUS, and CT/MRI of the pelvis were suspicious for local recurrence in 9, 7, 26, and 29 patients, respectively. CONCLUSIONS: TRUS is a highly sensitive tool in detecting local recurrence following cystectomy. It is easy to perform and inexpensive. We recommend TRUS in short intervals in all patients with high risk for local recurrence in order to detect cancer early.

[Role of androgen receptors in hormone-refractory prostate cancer: molecular basics and experimental therapy approaches]. / Die Rolle des Androgenrezeptors im hormonrefraktären Prostatakarzinom : Molekulare Grundlagen und experimentelle Therapieansätze.

The development of hormone-refractory prostate cancer cells is one of the major causes for the progression and high mortality rates in advanced prostate cancer (PCA). While the loss of the androgen receptor (AR) is the predominant mechanism for development of a hormone-insensitive disease in vitro, the first in vivo studies showed that the AR is still expressed or is even overexpressed in hormone-refractory PCA. In view of the increasing cases of PCA in the industrialized Western countries, a series of cell and molecular biological studies has led to the identification of various new factors and mechanisms that play a role during the development of hormone-refractory tumors. These findings should lead to the development of new therapeutic strategies.

[Ileal bladder substitute]. / Ileale Ersatzblasen.

The history of urinary diversion in general began in 1852 and started right away with continent diversion, i.e., ureterosigmoidostomy. Anastomosing an intestinal reservoir to the urethra was proposed by Tizzoni and Foggi in 1888. They replaced the bladder by an isoperistaltic ileal segment which was interposed between ureters and urethra in a female dog. In 1951 Couvelaire reactivated this idea of an ileal bladder substitute. Retrospectively many disappointing results of urinary diversion were often not caused by insufficient competence of the outlet mechanism, but because the intestinal reservoir maintained its peristaltic properties causing high pressure peaks. The decisive advance in ensuring continence, and thus an improvement in patient comfort, was achieved with the so-called low pressure reservoir. The main characteristics of this reservoir compared to those from intact intestinal segments are the larger diameter, the greater capacity with significantly low pressures, and the uncoordinated contraction of its wall. Transsection of the circular intestinal musculature when performing bladder augmentation had already been published by Rutkowski in 1899, Tasker in 1953, and Giertz in 1957. In 1969, Kock published the first results obtained with an ileal continent fecal reservoir in patients after total proctocolectomy. The significant advantages of interrupting the tubular structure of a reservoir obtained from intestine had been described much earlier. The need for reflux prevention is not the same as in ureterosigmoidostomy conduit or continent diversion. Reflux prevention in neobladders is even less important than in a normal bladder. When using nonrefluxing techniques, the risk of obstruction is at least twice that after direct anastomosis. Kidney function is not impaired by diversion if stenosis is recognized and managed. Patient health status is influenced more by underlying disease than by diversion. Orthotopic reconstruction has passed the test of time. In these patients life is similar to that in individuals with a native lower urinary tract. Until a better solution is devised orthotopic bladder reconstruction remains the best option for patients requiring cystectomy.

[Systemic therapy approaches in patients with bone metastases of urogenital malignancies]. / Systemische Therapieansätze bei Knochenmetastasen urogenitaler Tumoren.

Bone metastases develop commonly in patients with a variety of urogenital malignancies and are a major cause of morbidity and diminished quality of life in a significant proportion of urogenital carcinoma patients. For example, bone metastases occur in approximately 80% of patients with hormone-refractory prostate cancer and in approximately 25% of patients with renal cell carcinoma. A sufficient and early therapy is crucial since adequate therapy can lead to significant improvements in pain control and function and maintain skeletal integrity. The effective treatment of bone metastases requires multidisciplinary cooperation between urologists, oncologists, surgeons, nuclear medicine physicians and radiation oncologists. Analgesic measures, bisphosphonates, radionuclides, radiation therapy as well as surgical procedures are available. This review will focus mainly on the role of analgetics, bisphosphonates, radionuclides and radiolabelled bisphosphonates in the treatment of bone metastases.

Clinical value of transrectal ultrasound in the diagnosis of suspected neoplasia in the small pelvis.

PURPOSE: In daily clinical practice, it is challenging to accurately diagnose suspected neoplasias in the small pelvis by minimal invasive means, and CT-guided biopsy is often limited in its feasibility. The aim of our study was to evaluate whether transrectal ultrasound (TRUS)-guided biopsy can verify suspected neoplasias in the small pelvis histologically. MATERIAL AND METHODS: The study population consisted of 12 patients who underwent biopsy of suspected malignancy in the pelvis by TRUS. All patients had clinical signs of an advanced tumour stage and in all cases, biopsy utilising computerised tomography (CT scan) had been unsuccessful despite of a documented lesion on CT scan or magnetic resonance imaging. For the TRUS guided biopsy, a commercially available 3-dimensional 7.5-MHz-probe was used (Combison 530 D, GENERAL ELECTRIC, Milwaukee, USA). The probe was armed with an 18 G biopsy gun. RESULTS: In all patients, the suspected lesion was easily detectable by TRUS, and tissue for verification of the malignant origin of the lesions could be collected under real-time TRUS with only 2 patients needing anaesthesia. The biopsy cores were of excellent quality and adequate for conclusive pathological diagnosis. 6 cases of lymph node metastases of a transitional cell carcinoma were detected. 1 case of extended node metastasis in prostate cancer, 1 paravesical manifestation of recurrent cervical cancer, 1 metastasis of a paravesically infiltrating colon cancer and 2 cases of paravesical metastases of a gastric cancer were also diagnosed. In one case, extragenital endometriosis could be diagnosed. CONCLUSION: Based on our experience it can be stated that TRUS-guided biopsy is a reliable diagnostic tool for verification of the neoplastic origin of suspected masses in the small pelvis. In all cases with a history of unsuccessful CT guided biopsy, sufficient tissue cores for conclusive histology could be collected with our technique, and surgical exploration could be avoided. This technique is minimally invasive, without radiation exposure, well tolerated under analgesia, time efficient and cheap.

[Evidence-based pharmacological metaphylaxis of stone disease]. / Evidenzbasierte Pharmakologische Harnsteinmetaphylaxe.

Approximately one-fourth of urolithiasis patients are at high risk for recurrent stone formation or severe metabolic disturbances. These patients need specific metaphylaxis for effective stone prevention, adjusted to their individual metabolic risk. Recent recommendations for the pharmacological treatment of stone diseases are summarized in this article. For the different treatment options, evidence from the literature was assessed. In addition, a follow-up concept for pharmacologically treated high-risk stone formers is discussed.

[Salvage radical prostatectomy]. / Salvage-radikale Prostatektomie.

BACKGROUND: Following external beam radiation and interstitial radiation for prostate cancer, between 30% and 50% of the patients experience locoregional recurrence of their cancer. Although radical salvage prostatectomy is a secondary treatment option with curative intent, so far only a few hundred patients (<2%) worldwide have undergone this operation. The subject of this paper is a review of the world literature with reference to the frequency with this operation is performed and the technique, and also the prospects of success and possible complications. PATIENTS AND METHODS: After radiotherapy, approximately 30% of biopsies are positive. Nonetheless, only 536 cases of salvage radical prostatectomy had been reported in the world literature up to 2005. The diagnosis of a local recurrence was always confirmed by rectal punch biopsy, pelvic CT and bone scintigraphy. Salvage radical prostatectomy with or without nerve sparing, with pelvic lymphadenectomy and, in some patients with cystectomy plus urinary diversion was the operative treatment applied. RESULTS: Following secondary treatment after radiotherapy (RT), three parameters have been consistently identified as predictors of local failure: PSA nadir, time to nadir and PSA doubling time; clinical stage and type of first-line treatment are not helpful in predicting failure. The 5-year biochemical relapse-free survival rates are 77%, 71% and 28% for stages pT2, pT3a and pT3b/pN1, respectively. The success rate for salvage radical prostatectomy is thus similar to that for de novo radical prostatectomy for the same stages. In the past salvage radical prostatectomy following radiotherapy had a high complication rate. CONCLUSIONS: A salvage radical prostatectomy with curative intent is a radical prostatectomy following radiotherapy also performed with curative intent. The reasons for the few literature reports of salvage RPX are: (1) oncological misgivings (too long a period of observation of PSA by the radiation oncologist/urologist; (2) misgivings to do with surgical technique, as the operation is technically challenging and involves a high risk of complications, especially incontinence. In recent times the comorbidity rate has become acceptable in cases in which the indications have been correctly observed. We believe that salvage prostatectomy should be considered only for patients in good general health whose life expectancy is over 10 years and who have recurrent cancer confirmed by punch biopsy 1 year or longer after the completion of radiotherapy and whose cancer was initially in an early (T1-2) clinical stage before their radiotherapy. Ideally, serum PSA should be less than 10 ng/ml both initially (before radiotherapy) and before salvage surgery. In addition, patients should be highly motivated and able to accept the surgical morbidity (50% incontinence rate).

Neobladder emptying failure in males: incidence, etiology and therapeutic options.

PURPOSE: Neobladder reconstruction is considered the best option for patients requiring cystectomy. Limited information is available about incidence, etiology and therapeutic options for neobladder emptying failure in males. MATERIALS AND METHODS: In a retrospective study we analyzed the data of a consecutive series of 655 male patients (age range 23 to 82 years, median 63; followup range 0 to 208 months, median 36.5) who received an ileal neobladder following radical cystectomy at our institution. All patients had a complete followup until death or until December 2003. Data on all diagnostic and therapeutic procedures performed for neobladder emptying failure were collected. RESULTS: Of 655 patients 75 (11.5%) had at least 1 episode of failure emptying the neobladder requiring some form of therapy during followup. Failure was due to dysfunctional voiding in 23 patients (3.5%) and mechanical obstruction in 52 patients (8%). Causes of mechanical obstruction were benign strictures of the neovesicourethral anastomosis (23 patients, 3.5%) or the anterior urethra (11 patients, 1.7%), neoplastic obstruction by local tumor recurrence (13 patients, 2.0%) or a nonurological malignancy (1 patient, 0.2%), and obstruction by mucosal valves (3 patients, 0.5%) or a foreign body (1 patient, 0.2%). In 38 of 52 patients with mechanical obstruction of the neobladder outlet emptying was fully restored with endourological procedures, while in 14 of 52 patients long-term catheterization was necessary. Catheterization was the therapy of choice for all patients with dysfunctional voiding. CONCLUSIONS: Neobladder emptying failure is of major concern but is not an argument against orthotopic diversion. The overall rate of transient or permanent neobladder emptying failure in males is high but most of the mechanical causes can be managed endoscopically, while the rate of patients with long-term catheterization for dysfunctional voiding is relatively low.

[Prospective evaluation of prostate cancer screening in men with a family history of the disease]. / Prospektive Evaluierung der Prostatakarzinomfrüherkennung bei Männern mit familiärer Disposition.

BACKGROUND: Family history is one of the strongest risk factors for prostate cancer. In this prospective study we evaluated the results of prostate cancer screening performed in healthy brothers of prostate cancer patients. The detection rate of prostate cancer and the positive predictive value of the examinations were determined. MATERIAL AND METHODS: The study population comprised 513 healthy men who were 38-75 years of age (median 62.0 years). Of these men, 268 having only one affected brother with prostate cancer were assigned to the sporadic group, and 245 probands having 2-10 affected relatives were assigned to the familial group. An abnormal PSA and/or a pathological digital rectal examination (DRE) was noted in 17.5% of familial (43/245) and 15.8% of sporadic probands (35/268). A biopsy of the prostate was performed in 60.5% of familial (26/43) and 71.4% of sporadic (25/35) men with pathological findings. RESULTS: Prostate cancer was found in 15 of 26 familial (57.7%) and 16 of 25 sporadic (64.0%) probands by prostate biopsy. The overall detection rate was 6.0% (31/513). CONCLUSION: Due to an increased prevalence the detection rate of prostate cancer and the positive predictive value of PSA and/or DRE are higher in men with a family history as expected in an unselected population. Our data suggest that in predisposed men prostate cancer screening should be recommended early. Furthermore an early indication for prostate biopsy is necessary. This recommendation should also be applied if only one first-degree relative has prostate cancer.

[History of high-flow priapism: 1960-2005]. / Geschichte des High-flow-Priapismus: 1960-2005.

High-flow priapism caused by a pathological arterial influx to the cavernous bodies was first described by F.B. Burt in 1960. The pathophysiological differentiation of high- and low-flow priapism was developed in 1983. The development of diagnostic tools for differentiation of different forms of priapism and the progress in the therapy of high-flow priapism from arterial ligation to supraselective embolization is presented.

[Rational diagnostic and therapy of renal colic in the year 2005--what's new?]. / Rationale Diagnostik und Therapie der Nierenkolik im Jahr 2005--Was ist neu?

The acute flank pain is the most frequent urological emergency. Patients with renal colic are usually treated in emergency care units or by their family doctors and require immediate diagnosis and treatment. Up to 10 % of the population is estimated to suffer from kidney colic at least once in their lifetime. Besides, renal colic can occur during pregnancy and childhood, which require special attention when deciding therapy. Differential diagnosis of acute flank pain contains a series of diseases which belong not only in the urological field but need adequate directly therapy. Particularly, these principles should give useful advice, wherever patients are treated without urological department.

[Innovative concepts in early cancer detection and staging of localized prostate cancer]. / Innovative Diagnostik in der Früherkennung und beim Staging des lokalisierten Prostatakarzinoms.

Prostate cancer is the most common malignancy in males. Men aged 50 years and older are recommended to undergo an annual digital rectal examination (DRE) and determination of prostate-specific antigen (PSA) in serum for early detection. Fortunately, disease-specific mortality continues to decline as a result of advances in screening, staging, and patient awareness. However, about 30% of men with a clinically organ-confined disease show evidence of extracapsular extension or seminal vesicle invasion on pathological analysis. Consequently, there is a need for more accurate diagnostic tools for planning tailored treatment. A variety of modern imaging techniques has been implemented in an attempt to obtain more precise staging, thereby allowing for more detailed counseling, and instituting optimum therapy. This review highlights developments in prostate cancer imaging that may improve staging and treatment planning for prostate cancer patients.