Presentation of a method at the Exploration Stage according to IDEAL: Percutaneous nephrolithotomy (PCNL) under local infiltrative anesthesia is a feasible and effective method - retrospective analysis of 439 patients.

INTRODUCTION: This study addresses minimally invasive anesthesiologic and analgetic approaches for stone surgery in the upper urinary tract. Aim of this retrospective analysis is to compare feasibility, safety and complication rates of percutaneous nephrolithotomy (PCNL) under local infiltration anesthesia alone (Group I) and additive intravenous analgetics and/or sedative medications (Group II). MATERIAL AND METHODS: This is a single center study. A total of 439 patients have been included from November 2003 until March 2012. A total of 226 patients were assigned to Group I receiving local infiltration anesthesia alone, whereas 213 patients were assigned to Group II receiving additive intravenous analgetics and/or sedative medications. Demographic characteristics and stone characteristics have been evaluated to determine feasibility, complication rates for safety, and stone-free rates for effectiveness. The study and the reported technique have then been retrospectively analysed according to the IDEAL stages of surgical innovation. RESULTS: All included patients who accepted local infiltration anesthesia underwent PCNL successfully. The mean American Society of Anesthesiologists score (ASA) of the included patients was 2.15 ±0.37 (range, 1-4). PCNL was indicated in 138 patients due to pelvic calculi, in 171 patients due to renal calculi, in 66 patients due to partial staghorn, in 48 patients due to complete staghorn and in 16 patients due to upper ureteral stones. The total stone free rate in our patients was 78.4% over all stone localizations. Compared to the possibility of using additive intravenous analgetics and/or sedative medications we could show differences in the median age (p=0.005) suggesting that older patients did better tolerate the infiltration anesthesia than patients at younger ages. We did also remark not statistically significant differences in Group I and Group II as for number of tracts, operation duration, hemoglobin drop, fever, transfusion rate, and stone free rate, but not for severe complications such as perirenal hematoma, colon perforation, pleura perforation, AV fistula, skin fistula, and mortality rate. CONCLUSION: PCNL performed under local infiltration anesthesia is a feasible method. It provides satisfactory positive clinical outcomes. Younger age seems to predispose to conversion to extended anesthesiologic procedures. When retrospectively applying the IDEAL criteria, the method can be assigned to the E level or stage 2b.

Successful evacuation of large perirenal hematoma after extracorporeal shock wave lithotripsy (ESWL) - step 1 of the IDEAL recommendations of surgical innovation.

Larger perirenal hematomas after extracorporeal shock wave lithotripsy (ESWL) are sometimes related to the loss of renal function due to compression of the normal renal tissue. After computed tomography-guided drainage and locally applied urokinase, the hematoma was fractionally evacuated. This procedure is a save and fast way to recover normal renal function.

Preliminary Results of a Multicentre Study of the UBC Rapid Test for Detection of Urinary Bladder Cancer.

BACKGROUND/AIM: UBC Rapid is a test detecting fragments of cytokeratins 8 and 18 in urine. These are cytokeratins frequently overexpressed in tumor cells. We present the first results of a multi-centre study using UBC Rapid in patients with bladder cancer and healthy controls. MATERIALS AND METHODS: Clinical urine samples from 92 patients with tumors of the urinary bladder (45 low-grade and 47 high-grade tumors) and from 33 healthy controls were used. Urine samples were analyzed by the UBC Rapid point-of-care (POC) system and evaluated both visually and quantitatively using a concile Omega 100 POC reader. For visual evaluation, different thresholds of band intensity for considering a test as positive were applied. Sensitivities and specificities were calculated by contingency analyses. RESULTS: We found that pathological concentrations by UBC Rapid are detectable in urine of patients with bladder cancer. The calculated diagnostic sensitivity of UBC Rapid in urine was 68.1% for high-grade, but only 46.2% for low-grade tumors. The specificity was 90.9%. The area under the curve (AUC) after receiver-operated curve (ROC) analysis was 0.733. Pathological levels of UBC Rapid in urine are higher in patients with bladder cancer in comparison to the control group (p<0.0001). CONCLUSION: UBC rapid can differentiate between patients with bladder cancer and controls. Further studies with a greater number of patients will show how valuable these results are.

Clinical and pathological features of metastatic adenocarcinoma of the prostate to the ileum.

We present a case of a 74-year-old white male with a history of prostate cancer with unusual metastasis to the ileum, and with ileus as a very unusual first symptom of prostate cancer. This patient presented to us with histologically confirmed metastasis of the ileum after resection in the Department of Surgery.

External validation of an artificial neural network and two nomograms for prostate cancer detection.

Background. Multivariate models are used to increase prostate cancer (PCa) detection rate and to reduce unnecessary biopsies. An external validation of the artificial neural network (ANN) "ProstataClass" (ANN-Charité) was performed with daily routine data. Materials and Methods. The individual ANN predictions were generated with the use of the ANN application for PSA and free PSA assays, which rely on age, tPSA, %fPSA, prostate volume, and DRE (ANN-Charité). Diagnostic validity of tPSA, %fPSA, and the ANN was evaluated by ROC curve analysis and comparisons of observed versus predicted probabilities. Results. Overall, 101 (35.8%) PCa were detected. The areas under the ROC curve (AUCs) were 0.501 for tPSA, 0.669 for %fPSA, 0.694 for ANN-Charité, 0.713 for nomogram I, and 0.742 for nomogram II, showing a significant advantage for nomogram II (P = 0.009) compared with %fPSA while the other model did not differ from %fPSA (P = 0.15 and P = 0.41). All models overestimated the predicted PCa probability. Conclusions. Beside ROC analysis, calibration is an important tool to determine the true value of using a model in clinical practice. The worth of multivariate models is limited when external validations were performed without knowledge of the circumstances of the model's development.

Outcome prediction for prostate cancer detection rate with artificial neural network (ANN) in daily routine.

BACKGROUND: We evaluated the use of the artificial neural network (ANN) program "ProstataClass" of the Department of Urology and the Institute of Medical Informatics at the Charité-Universitätsmedizin Berlin in daily routine to increase prostate cancer (CaP) detection rate and to reduce unnecessary biopsies. MATERIALS AND METHODS: From May 2005 to April 2007, a total of 204 patients were included in the study. The Beckman Access PSA assay was used, and pretreatment prostate specific antigen (PSA) was measured prior to digital rectal examination (DRE) and 12 core systematic transrectal ultrasound (TRUS) guided biopsies. The individual ANN predictions were generated with the use of the ANN application for the Beckman Access PSA and free PSA assays, which relies on age, PSA, percent free prostate specific antigen (%fPSA), prostate volume, and DRE. Diagnostic validity of total prostate specific antigen (tPSA), %fPSA, and the ANN was evaluated by ROC curve analysis. RESULTS: PSA and %fPSA ranged from 4.01 to 9.91 ng/ml (median: 6.65) and 5% to 48% (median: 15%), respectively. Of all men, 46 (22.5%) demonstrated suspicious DRE findings. Total prostate volume ranged from 7.1 to 119.2 cc (median: 35). Overall, 71 (34.8%) CaP were detected. Of men with suspicious DRE, 28 (60.9%) had CaP on initial biopsy. The ANN was 78% accurate in the original report. The AUC of ROC curve analysis was 0.51 for PSA, 0.66 for %PSA, and 0.72 for the ANN-Output, respectively. CONCLUSIONS: Our results in this independent cohort show that ANN is a very helpful parameter in daily routine to increase the CaP detection rate and reduce unnecessary biopsies.

Idiopathic giant abdominal lymph cyst: a case report.

INTRODUCTION: Giant lymph cysts are a relatively frequent complication after surgical procedures in the abdomen, often after kidney transplantation, but there are also cases after pelvic surgery such as lymphadenectomy and others. In the recent literature, there have been no reported cases of idiopathic giant lymphocyst. CASE PRESENTATION: We present the case of a 76-year-old Caucasian man who had a lymph cyst he had known of for more than 15 years. Laparoscopic treatment was necessary because of hydronephrosis of the left kidney. CONCLUSION: This case shows that laparoscopic drainage and partial resection of the lymph cyst is a safe and effective treatment.

Does a new ultrasound probe change the complication rates of transrectal ultrasound-guided needle biopsies of the prostate?

BACKGROUND: Transrectal ultrasound-guided prostate needle biopsies are performed to diagnose prostate cancer. This study prospectively evaluated the safety, morbidity and complication rates with two different ultrasound probes. PATIENTS AND METHODS: Three huntred and thirty-two patients were biopsied using a biplane 7.5 MHz probe (GE Medical Systems Kretz Ultrasound, Zipf, Austria) and 101 patients using a biplane 5-10 MHz probe (BK-Medical, Herlev, Denmark). Four weeks after the procedure the patients were asked to fill out a questionnaire. RESULTS: There were 3 major and 75 minor complications. The most common complication was haematuria in 8.1% of cases, followed by pain with urination in 5.3% of cases. After changing the ultrasound probe, the complication rates were slightly higher, but no statistical difference in any of the complication rates was found between the two groups. CONCLUSIONS: Changing the method within the same team has no influence on complication rates and on prostate cancer detection rates.

Evaluation of symptoms and patients' comfort for JJ-ureteral stents with and without antireflux-membrane valve.

OBJECTIVES: To evaluate safety and patients' comfort by using the ureteral stent symptom questionnaire. Ureteral stents are used to provide upper urinary-tract drainage. METHODS: A total of 133 JJ-ureteral stents with and without antireflux-membrane valve as consecutive referrals for therapy of hydronephrosis have been inserted. Four weeks after insertion of the ureteral stent, the patients were asked about pain while urination, flank pain due to reflux, and the comparison with former stents. Ultrasound of the kidney for hydronephrosis grade and creatinine value as follow-up have been documented. Statistical analysis included chi(2) test after Pearson correlation computed and performed by SPSS software. RESULTS: We found a high correlation between the JJ-ureteral stent used and the detection of a hydronephrosis (P = .004). More patients who had a JJ-ureteral stent without valve complained of flank pain (P <.0005) and pain in the bladder (P <.0005). Patients who had a ureteral stent before were asked to compare new stents with the former ones. No patients with a JJ-ureteral stent with valve found this one to be worse than what they had before. CONCLUSIONS: JJ-stent related symptoms are a major problem for these patients. New stent designs and materials will be developed in the future to reduce stent-related morbidity and improve patient comfort. JJ-ureteral stents with an antireflux-membrane valve have a lower complication rate and provide a higher patient comfort compared with stents without valve.

Reconstruction of the urethra with a Surgisis onlay patch in urethral reconstructive surgery: two case reports.

INTRODUCTION: We present two case reports of patients with recurrent stricture of the urethra. We used Surgisis((R)) for reconstruction. CASE PRESENTATION: In these two case reports, we show the positive results of reconstructive surgery with Surgisis((R)) as an alternative surgical approach to common onlay patch surgery of the urethra performed on two Caucasian patients: a 48-year-old man and a 55-year-old man. CONCLUSION: Compared to buccal mucosa flap or foreskin graft surgeries for urethral reconstruction, reconstructive surgery with Surgisis((R)) is considered a relevant therapeutic alternative because of the shorter operation time and the preventable surgery of the buccal cavity or foreskin.

Multimodal stone therapy for two forgotten and encrusted ureteral stents: a case report.

INTRODUCTION: Ureteral stent placement is a common procedure in daily urologic practice. To manage the problems of forgotten stents for many years needs multimodal stone therapy. CASE PRESENTATION: We present a case of a 26-years-old Caucasian, white woman with two forgotten encrusted ureteral stents for 48 months. Multimodal stone therapy including extracorporeal shock wave (SWL), percutaneous nephrolithotomy (PCNL), ureterorenoscopy (URS), cystolithotripsy with Lithoclast, and open surgery was necessary to remove all the stones. Using the described combination of techniques, our patient was rendered stone and stent free. Urologists should bear in mind the presence of severe encrustations when they have to deal with a forgotten stent. CONCLUSION: This case shows that combined urologic techniques can achieve successful and safe management of forgotten stents, but treatment should be tailored to the volume of encrustation and associated stone.

Complications and risk factors of transrectal ultrasound guided needle biopsies of the prostate evaluated by questionnaire.

BACKGROUND: Transrectal ultrasound guided prostate needle biopsies are routinely performed to diagnose and stage prostate cancer. We prospectively evaluated the safety, morbidity, and complication rate. MATERIALS AND METHODS: We studied 336 patients who underwent transrectal ultrasound guided prostate needle biopsy. A post-biopsy questionnaire was sent to the patients 4 weeks after biopsy concerning questions about minor complications. Information on major complications was obtained by telephone interview. RESULTS: There were 2 major and 48 minor complications. The most common complication was hematuria in 6.5% of cases, followed by pain while urinating in 6.0% of cases. There was no statistically significance difference between hematuria and aspirin/thrombolytic drug use (P = 0.170) and between positive microbiology in urine and elevated temperature (P = 0.665). CONCLUSIONS: Transrectal ultrasound guided prostate needle biopsy is safe for diagnosing prostate cancer with few major and minor complications. Aspirin/thrombolytic drug use in patients' history is no risk factor for hematuria. Positive microbiology in urine before biopsy is no risk factor for a higher infection rate.

Chemotherapy with gemcitabine, paclitaxel, and cisplatin in the treatment of patients with advanced transitional cell carcinoma of the urothelium.

Chemotherapeutic agents are active in advanced bladder cancer, and various combinations have shown promising results. The objective of this study was to evaluate the efficacy of combination chemotherapy with gemcitabine, paclitaxel, and cisplatin in patients with advanced urothelial carcinoma. Fifty-nine patients with metastatic or locally advanced transitional cell carcinoma of the urothelium were treated between 2000 and 2005. No patient had received any previous systemic chemotherapy. All patients received chemotherapy intravenously with gemcitabine at a dose of 1000 mg/m(2) on days 1 and 8, paclitaxel at a dose of 80 mg/m(2) on days 1 and 8, and cisplatin at a dose of 50 mg/m(2) on day 2. Treatment courses were repeated every 21 days. After completion of four to six courses in this regimen an intravenous application of gemcitabine was repeated every 28 days at a dose of 1000 mg/m(2). Fifty-nine patients were treated between 2000 and 2005. Nine patients (15%) had >or=1 visceral site of metastases, and no patient had received any previous systemic chemotherapy. Forty-eight patients (81%) achieved objective responses to treatment (56% complete responses). The median actuarial survival was 22 months, and the actuarial 1-year and 2-year survival rates were 68% and 39%, respectively. After a median follow-up of 17.5 months, 29 patients remained alive and 25 were free of disease progression. The median progression-free survival for the entire group was 10 months. The median survival time for patients with an Eastern Cooperative Oncology Group (ECOG) status of 0, 1, and 2 was 37.5, 17, and 12 months, respectively. Grade 3-4 neutropenia occurred in 39% of the patients. The combination of gemcitabine, paclitaxel, and cisplatin is a highly effective and tolerable regimen for patients with advanced urothelial carcinoma. This treatment should be considered as a suitable option that deserves further prospective evaluation. The ECOG performance status is an important predictive factor for survival.