[Urinary diversion in old patients (80+ years)]. / Harnableitung beim alten Patienten (80+).

With increasing life expectancy there is also an increased need for the management of older (≥ 80 years) patients with the diagnosis of muscle-invasive bladder cancer. Radical cystectomy with urinary diversion is the state of the art treatment (with neoadjuvant chemotherapy, as long as the patient is fit enough). Choosing the best urinary diversion with respect to morbidity compared to functionality and quality of life remains a challenge in these patients. Physical age alone is not decisive for making a decision. A thorough preoperative assessment of medical features, physical and cognitive impairments is more important. Older patients are generally provided with an ileal conduit as an incontinent urinary diversion, as the intervention involves reduced operating times and complexity compared to continent urinary diversions; however, in the case of good health status with an adequate life expectancy and sufficient compliance, continent diversions may be considered even in aged candidates. In the case of multimorbid patients with a high perioperative risk, ureterostomy with permanent ureteric stents is an important alternative. Most importantly, a thorough preoperative counselling enables patients to reach an informed decision.

[Safety and efficacy of en bloc vs. conventional transurethral resection of bladder tumors: a meta-analysis and systematic review]. / Sicherheit und Effizienz der en bloc vs. konventionellen transurethralen Resektion von Blasentumoren: eine Metaanalyse und systematic Review.

BACKGROUND: En bloc tumor resection of bladder tumors (ERBT) is a novel alternative procedure to conventional resection of bladder tumor (cTURBT), which might help to address common problems of the standard method, such as inadequate detrusor muscle in specimens, high re-resection rates and high recurrence rates. OBJECTIVE: To analyze current data on ERBT in efficacy and safety compared to cTURBT. DATA SOURCES: PubMed. STUDY SELECTION: Two independent authors identified trials based on keywords and inclusion criteria. A third author was consulted in case of discrepancies. Screening keywords: ERBT, en bloc transurethral resection of bladder tumor, TURBT en bloc. A meta-analysis of 13 studies was performed. The effect size was estimated based on odds ratios and mean differences including their corresponding two-sided 95% confidence intervals. DATA SYNTHESIS: The analyzed studies comprised a homogenous collective in terms of tumor size, tumor multiplicity and tumor stage. Operation time did not significantly differ between the methods. Differences were observed in hospitalization and catheterization time in favor of ERBT. Reported complications did not show clear differences. There was significantly more detrusor muscle in the specimens in the ERBT group. No significant differences were found in recurrence up to 2 years of follow-up. CONCLUSION: ERBT is a safe alternative to conventional TURBT with promising features regarding effective resection of detrusor muscle. More standardized data on recurrence rates, different resection modalities and resection margin results are needed.

[Management of geriatric patients with benign prostatic hyperplasia]. / Das Management geriatrischer Patienten mit benignem Prostatasyndrom.

Multimorbid older men are increasingly more common in daily practice and present a challenge because they are often affected by lower urinary tract symptoms (LUTS) and age-associated benign prostatic hyperplasia (BPH). In order to identify possible risks in diagnostics, therapy and counselling at an early stage, screening for functional deficits or risk factors with standardized procedures is helpful. An initial screening with subsequent assessment of everyday skills using the Barthel Index, Timed up & Go Test, and a cognitive test are recommended. If frailty syndrome is detected, it should be taken into account during the pre-, peri-, and postoperative management, as it may indicate increased morbidity and mortality. Noninvasive methods for reducing the prostate volume without anesthesia can be a therapy option in older multimorbid patients, and with individual planning and consideration of risk factors, up to 70% of individuals become symptom-free. However, there is currently no gold standard for this vulnerable patient group. Number of medications and concomitant diseases and higher need for help are per se risk factors for unsatisfactory results after transurethral resection of the prostate (TURP) or laser vaporization. With drug therapy, concomitant medications and their interactions, especially in the cytochrome system, an existing multimorbidity and adherence to therapy must be taken into account. Combination therapies may complement each other and may bridge the time until surgery. Minimally invasive methods that can be performed without general anesthesia are suitable for geriatric patients, especially those with recurrent retention. Studies with the Rezüm® system (NxThera Inc., Maple Grove, MN, USA) and UroLift® (NeoTract Inc., Pleasanton, CA, USA) show that about 70% of patients can be relieved from the permanent catheter.

[Urological infections and antibiotic management in geriatric patients]. / Urologische Infektionen und Antibiotikamanagement bei geriatrischen Patienten.

Both the demographic shift and progress in medicine are resulting in an increasingly longer life expectancy. It is presumed that a mean age of 90 years will be achieved within the next decade in many countries. Thus, geriatric medicine, which is committed to the specific needs of older, often frail and frequently comorbid patients, is becoming increasingly more important. The prevalence of infections of the genitourinary tract increases with age, simultaneously, a critical and conscious use of antibiotics is required in terms of antimicrobial treatment. The intention of the present review is to make the reader aware of the specific characteristics of urinary tract infections and asymptomatic bacteriuria in the older patient population in terms of epidemiology, spectrum of pathogens and resistance as well as the indications for and performance of antimicrobial treatment.

[Endoscopic enucleation of the prostate]. / Endoskopische Enukleation der Prostata.

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

[Follow-up of bladder cancer : The right examinations at the right time]. / Tumornachsorge des Harnblasenkarzinoms : Die richtigen Untersuchungen zum richtigen Zeitpunkt.

Schedules for the follow-up (FU) of bladder cancer patients are predominantly based on studies with low level of evidence and the resulting guidelines' recommendations that are often founded on expert consensus. FU of non-muscle invasive bladder cancer (NMIBC) includes cystoscopy and cytology as standard, and imaging modalities to a lower extent. FU of muscle-invasive bladder cancer (MIBC) depends primarily on the therapeutic modality chosen and on the stage of disease. In this scenario, FU is complemented by functional and quality of life related aspects. These apply even more for FU in palliative situations. Here, the individual focus is on examinations that might have a consequence in terms of survival and/or symptom relief.

[Extracorporeal shock wave lithotripsy]. / Extrakorporale Stoßwellenlithotripsie.

Interventional treatment of stones essentially consists of three treatment modalities. Extracorporeal shockwave lithotripsy (ESWL), in addition to uterorenoscopy (URS) and percutaneous nephrolitholapaxy (PCNL) is an essential treatment pillar and is the only noninvasive therapy option for the treatment of urinary stones. After a long period of ESWL being the leading choice in stone treatment, the number of SWL interventions diminished in recent years in favor of the other two treatment modalities (URS and PCNL). This article describes the indications, surgical technique and management of complications of SWL.

[Surgical positioning techniques in urology : Tips and tricks]. / Lagerungstechniken in der Urologie : Tipps und Tricks.

Correct positioning of patients during preoperative preparations is essential for success of the intervention to avoid any positioning trauma and to provide the best access to the targeted structures. The appropriate positioning (and optimal performance) means that complications are avoided and also makes an essential contribution to the smooth course of the surgical intervention. A correct position is essential particularly in urology because the organs assigned to the discipline of urology are anatomically mostly difficult to reach. A further important function of the correct positioning technique is the avoidance of injuries to the patient. This article summarizes the most common positioning techniques in urological interventions with special emphasis on the explanation of practical advice, helpful tips and possible complications that can enable even junior surgeons to correctly perform the appropriate positioning technique.

[Ureterorenoscopy]. / Ureterorenoskopie.

Ureterorenoscopy (URS) is a minimally invasive treatment option for removal of kidney stones, which has gained importance in this field over the past two decades. This technique has replaced extracorporeal shock wave lithotripsy (ESWL) stone surgery for many indications. It is also particularly important in the diagnostics and treatment for tumors of the upper urinary tract. This article describes the indications, surgical technique and management of complications of URS.

[Operative technique for percutaneous nephrolithotomy]. / Operative Technik der perkutanen Steintherapie.

Percutaneous nephrolithotomy (PCNL) is a well-established minimally invasive treatment option for removal of kidney stones. This technique has now replaced open stone surgery for virtually all indications. This article describes the indications, the surgical technique and the complication management of PCNL.

[Therapy of low-grade nonmuscle-invasive bladder cancer]. / Therapie des nicht-muskelinvasiven Low-grade-Harnblasenkarzinoms.

Nonmuscle-invasive bladder cancer (NMIBC) comprises a very heterogeneous group of malignancies; the biological behavior of these tumors depends primarily on their grading. Low-grade NMIBC are characterized by a high propensity for recurrence but a very low risk for progression to muscle invasion or metastatic disease. Thus, the first line goal of diagnostic procedures and therapy is reliable visualization and complete resection of all foci. Cytology and other urine-based markers fail due to insufficient sensitivity. A second resection might be necessary only in selected intermediate risk cases; the positive effect of maintenance instillation protocols beyond a single postoperative instillation is questionable for the majority of patients. Risk stratification, e.g., according to the EORTC or EAU proposals, also makes sense in low grade NMIBC.

[Indications for nephron-sparing surgery. Analysis over a 13-year period in the context of changing guidelines]. / Indikationsstellung zur organerhaltenden Nierentumorchirurgie. Analyse eines 13-Jahres-Zeitraums vor dem Hintergrund sich wandelnder Leitlinien.

BACKGROUND: The indications for nephron-sparing surgery have been considerably extended by guideline recommendations in recent years. It remains unclear whether clinical practice still reflects these new guidelines. OBJECTIVE: In this retrospective, monocentric analysis at a tertiary referral center the indications for partial nephrectomy over a 13-year period were evaluated. METHODS: In a retrospective database analysis all cases of surgically treated renal masses from 2001 to 2013 were evaluated. Besides demographic, tumor-specific and perioperative variables the development of the surgical technique depending on the tumor stage was evaluated. RESULTS AND DISCUSSION: The proportion of nephron-sparing surgery cases increased from below 20 % in 2001 to 35 % in 2013 in the entire cohort. For stage T1a tumors, partial nephrectomy increased from approximately 50 % to over 90 % and for T1b tumors it rose from 10 % to 50 %. Logistic regression revealed stage 1 tumors to be predictive of partial nephrectomy over the complete evaluation period. Extending the indications for partial nephrectomy even to higher stages is under discussion but not yet supported by data from prospective, controlled studies.

[Metastasized renal cell carcinoma. Measurement of plasma levels of the tyrosine kinase inhibitors sunitinib, sorafenib and pazopanib]. / Metastasiertes Nierenzellkarzinom. Bestimmung der Plasmaspiegel der Tyrosinkinaseinhibitoren Sunitinib, Sorafenib und Pazopanib.

BACKGROUND: Several tyrosine kinase inhibitors (TKI) are used in the treatment of metastasized renal cell carcinoma (mRCC). This article presents a feasibility study for the measurement of plasma levels of sunitinib, sorafenib and pazopanib using liquid chromatography tandem mass spectrometry (LC-MS/MS). METHODS: A total of 23 patients suffering from mRCC under treatment with sunitinib (n=16), sorafenib (n=3) and pazopanib (n=4) were included. Plasma samples (100 µl) were separated by liquid chromatographic analysis and the plasma levels of the TKIs determined by tandem mass spectrometry. RESULTS: The plasma levels of sunitinib, sorafenib and pazopanib were measurable and the results reproducible. During storage of the plasma samples for 1 week at 4°C no significant decrease of the initial concentration was found. The highest plasma levels detected were 99 ng/ml for sunitinib, 9.8 µg/ml for sorafenib and 63 µg/ml for pazopanib. We could show variability in plasma levels according to changes in dosage of TKIs or during treatment-free intervals. CONCLUSION: Measurement of TKI plasma levels using LC-MS/MS is feasible. Further clinical studies have to be conducted to examine if there are any threshold levels for the incidence of adverse events or response to treatment.

[Predictors for presence of residual tumor in follow-up transurethral resection of bladder tumors: single center results]. / Vorhersageparameter für das Vorliegen eines Residualtumors bei der TUR-B-Nachresektion: single-center-Ergebnisse.

BACKGROUND: European Association of Urology (EAU) guidelines recommend a follow-up transurethral resection of bladder tumors (reTUR-B) for intermediate and high-risk non-muscle invasive bladder cancer (NMIBC) 2-6 weeks after the initial resection. The purpose of this study was to find parameters which indicate the presence of residual tumor in reTUR-B and to evaluate the prognostic value. PATIENTS AND METHODS: The data from all patients treated with TUR-B between January 2005 and December 2008 were retrospectively evaluated. The residual tumor rate was correlated with age, sex, staging, grading, risk group, multifocality and surgeon's level of training. RESULTS: A total number of 555 TUR-B operations were carried out and 179 patients received reTUR-B according to the EAU guidelines. Age (p=0.8), sex (p=0.7), initial staging (p=0.2), initial grading (p=0.3) and surgeon's level of training (p=0.7) did not have an impact on the rate of residual tumor in reTUR-B. Tumors categorized as high risk according to the EAU risk score in initial TUR-B (p<0.01) and multifocality (p=0.01) were associated with significantly higher rates of residual tumor. CONCLUSIONS: A reTUR-B is strongly indicated in high risk bladder tumors as well as multifocal tumors showing a significantly increased residual tumor rate. Other clinical parameters showed no prognostic value for the existence of residual tumor in reTUR-B.

[Bladder cancer in focus: update 2012 of the German Bladder Cancer Association]. / Das Harnblasenkarzinom im Fokus : Update 2012 des Deutschen Forschungsverbundes Blasenkarzinom e. V.

The German Bladder Cancer Association (DFBK) invited its members to the 3rd annual meeting 2012 in Hannover 4 years after the official founding. The meeting was directed to discuss the progress of ongoing and newly initiated projects and collaborations. In this article we will introduce current research activities and collaborations of the DFBK and would like to invite interested researchers to join this national interdisciplinary research association. The aim of the DFBK is to initiate interdisciplinary collaboration and to support scientific discussions among its members. For further information please visit our website at www.forschungsverbund-blasenkarzinom.de.

[Transobturatoric sling procedures for stress urinary incontinence in elderly women: indication and results]. / Transobturatorische Bandplastiken in der Inkontinenztherapie bei älteren Patientinnen : Indikation und Ergebnisse.

Urinary incontinence is one of the great challenges in geriatrics. The prevalence is high in elderly women and increases continuously with increasing age. The consequences of incontinence can be severe and are often associated with social isolation. Placement of a transobturatoric sling is a frequently used option in the surgical treatment of stress incontinence. Continence rates are high and associated with low side effects but several sub-analyses have shown poorer success rates and an increase in perioperative morbidity in women over 70 years. Recent studies, however, point to similarly good success rates and thus provide an effective and safe treatment option.

[Multiparametric MRI, elastography, contrastenhanced TRUS. Are there indications with reliable diagnostic advantages before prostate biopsy?]. / Multiparametrisches MRT, Elastographie, kontrastmittelverstärkter Ultraschall. Gibt es Indikationen mit verlässlichem diagnostischem Zugewinn vor Prostatastanzbiopsie?

Prostate cancer (PCA) is the most common malignancy in men with an increasing incidence and is responsible for about 11,000 deaths per year in Germany. Fortunately, the mortality of PCA has decreased in recent years despite the rising incidence reflecting improvements in diagnostic methods. Many new innovations in imaging techniques for PCA are available and may be helpful in early detection of PCA. Contrast-enhanced sonography, computer-assisted sonography, elastography and multiparametric magnetic resonance imaging (MRI) seem to be the most promising methods to increase the detection rate of PCA during diagnostic work-up. The value of these new innovative techniques concerning improvement in PCA detection is reviewed.