Postoperative change in Gleason score of prostate cancer in fusion targeted biopsy: a matched pair analysis.

OBJECTIVE: To evaluate if MRI/ultrasound fusion based targeted biopsy (FBx) leads to a reduced rate of change in Gleason score (GS) compared to prostatectomy specimen. METHODS: The histopathological findings of the biopsy of the prostate and the radical prostatectomy (RP) specimen of 210 patients who were referred to our hospital between 2012 and 2017 were compared retrospectively in this study. One hundred and five patients who underwent FBx combined with ultrasound-guided 12-core biopsy of the prostate (SBx) were matched with 105 patients who underwent SBx only. This study evaluated the rate of up- or downgrading in the RP specimen in both groups and compared the results via matched pair analysis. RESULTS: Concordance in Gleason grade group (GGG) was found in 52/105 patients (49.5%) in SBx and in 49/105 patients (46.7%) with FBx (p = 0.679). The rate of downgrading was statistically significant (p = 0.014) and was higher in the FBx group (14/105 patients, 13.3%) than in the SBx group (4/105 patients, 3.8%). A higher rate of upgrading was seen in SBx (49/105 patients; 46.7%) compared to FBx (42/105 patients; 40%), with no statistical significance (p = 0.331). The change in GGG from biopsy to final pathology in patients with GGG 1 and 2 at biopsy level was not statistically significant (p = 0.168). CONCLUSION: FBx does not decrease the rate of upgrading between biopsy and final pathology in RP specimens. Our results indicate that FBx tends to overestimate the final GGG compared to SBx.

[Management of ureteral injuries]. / Management von Harnleiterverletzungen.

Ureteral injuries account for less than 3% of genitourinary injuries. Most of them are caused iatrogenically during abdominal surgery. The symptoms are often non-specific and do not aid in diagnosis. The later the injury is detected, the more often complications occur. Therefore, in such situations it is important to consider the possibility of ureteral injury and initiate further diagnostic steps as soon as possible. A variety of diagnostic tests are available. In addition to the direct inspection of the ureters and retrograde ureteropyelography, computed tomography (CT) urography is routinely used. Based on the time of diagnosis as well as the extent and the localization of the injury, the further procedure can be determined. For minor injuries, the insertion of a ureteral splint is usually the treatment of choice. In the case of higher grade damage, operative reconstruction by one of several possible surgical procedures is indicated.

[Value of imaging in upper urinary tract tumors]. / Wertigkeit der Bildgebung bei Tumoren des oberen Harntraktes.

BACKGROUND: Staging of bladder cancer, hematuria as well as the evaluation of unclear findings of the kidneys and ureters are the most frequent indications for imaging of the upper urinary tract (UUT). Endourological assessment of the UUT is much more invasive compared to imaging of the bladder, raising the question of the optimal imaging technique. Several technical improvements regarding computed tomography (CT) as well as magnetic resonance imaging (MRI) were implemented in recent years. OBJECTIVES: To compare the efficacy and limitations of the most important imaging techniques regarding the UUT. MATERIALS AND METHODS: Systematic review of the literature and current German, European, and American guidelines regarding bladder cancer, urothelial carcinoma of the UUT and hematuria. RESULTS: The CT-based urography has superseded excretory urography and is the first choice for imaging of the UUT. In case of contraindications, MRI is a feasible alternative. In all cases, a urography phase is indispensable. CONCLUSIONS: Imaging of the UUT has to be used in a reasonable combination together with endourological methods and cytology. Optical coherence tomography, confocal laser endomicroscopy and scientific innovations such as radiomics might improve UUT imaging and differential diagnosis of UUT lesions in the future.

[Neuroendocrine prostate cancer]. / Neuroendokrines Prostatakarzinom.

Neuroendocrine prostate cancer (NEPC) mostly occurs as a treatment-emergent adaptive response under the pressure of intensive androgen deprivation treatment (t-NEPC). Approximately 30-40% of patients with metastatic castration-resistant prostate cancer (mCRPC) also have neuroendocrine involvement. In contrast primary small cell prostate cancer is very rare (<1%). A t­NEPC should be clinically suspected in patients who have particularly aggressive mCRPC but a disproportionately low prostate-specific antigen (PSA) level and elevated neuroendocrine tumor markers, such as chromogranin A and neuron-specific enolase. The initial Gleason score was shown to be an independent factor correlated to the risk of development of t­NEPC. Treatment is oriented to that of small cell lung cancer. In patients with negative PSA levels, chemotherapy with cisplatin and etoposide is the first line treatment, for which response rates in the range of 30-60% with a median survival time of usually less than 1 year can be achieved. In patients with much higher serum PSA levels, chemotherapy with carboplatin plus docetaxel should be considered.

[Stricture of the vesicourethral anastomosis after radical prostatectomy]. / Die Striktur der vesikourethralen Anastomose nach radikaler Prostatektomie.

BACKGROUND: The development of a stricture of the vesicourethral anastomosis is a serious complication after radical prostatectomy. Strictures occur in 5-8% of patients after radical prostatectomy. SYMPTOMS: Usually the clinical symptoms include an irritative and obstructive component similar to benign prostatic hyperplasia. In rare cases, patients suffer from partial or complete stress incontinence as a result of the anastomotic stricture. DIAGNOSTICS: The diagnostic workup is similar to the procedure for urethral strictures. In addition to uroflowmetry, a cystourethrogram (CUG) or, if necessary, a micturating cystourethrogram (MCU) can be performed. A urethrocystoscopy can be performed to ensure the diagnosis. THERAPY: In most cases, endoscopic procedures were performed for treatment. Beside a transurethral dilation of the stricture or the Sachse urethrotomy, the most common procedure is transurethral resection to treat the stricture. However, all procedures are associated with a high recurrence rate. In recurrent strictures, open surgical procedures, usually a perineal reanastomosis, should performed early. CONCLUSION: Endourological procedures like transurethral resection are a good treatment option, but due to the high recurrence rates, open surgical procedures should be discussed and if necessary should be performed early.

[Diagnostic workup of urethral strictures]. / Diagnostischer Workup bei der Harnröhrenstriktur.

Urethral stricture is a narrowing of the urethra due to scar tissue. It causes obstructive voiding dysfunction and can lead to long-term damage of the entire urinary tract. The probability of therapeutic success is dampened by a high rate of recurrence. Therefore, a careful taking of the patient's history and further diagnostics are crucial for finding the appropriate form of therapy. This review highlights the clinical presentation and diagnostic workup of urethral strictures.

[Bulbar urethral strictures : A trivial urological disease or a surgical challenge?] / Die bulbäre Harnröhrenstriktur : Banale urologische Erkrankung oder chirurgische Herausforderung?

Urethral strictures are often located in the bulbar urethra, and bulbar strictures are commonly due to urethral trauma. Diagnosis is confirmed by radiographic imaging of the urethra. In cases of short primary bulbar strictures, a simple internal urethrotomy may be curative. In contrast, open surgery should be performed in long segment or recurrent strictures because recurrence rates are near 100% in these cases. Depending of the actual findings and comorbidities, end-to-end anastomosis, graft urethroplasty, flap urethroplasty, or perineal urethrostomy may be used. If definitive treatment using open surgery is delayed and multiple endoscopic treatments are tried, urethroplasty becomes more complex and success rates of definitive treatment decline.

[Neuroendocrine prostate cancer]. / Neuroendokrines Prostatakarzinom.

Neuroendocrine prostate cancer (NEPC) mostly occurs as a treatment-emergent adaptive response under the pressure of intensive androgen deprivation treatment (t-NEPC). Approximately 30-40% of patients with metastatic castration-resistant prostate cancer (mCRPC) also have neuroendocrine involvement. In contrast primary small cell prostate cancer is very rare (<1%). A t­NEPC should be clinically suspected in patients who have particularly aggressive mCRPC but a disproportionately low prostate-specific antigen (PSA) level and elevated neuroendocrine tumor markers, such as chromogranin A and neuron-specific enolase. The initial Gleason score was shown to be an independent factor correlated to the risk of development of t­NEPC. Treatment is oriented to that of small cell lung cancer. In patients with negative PSA levels, chemotherapy with cisplatin and etoposide is the first line treatment, for which response rates in the range of 30-60% with a median survival time of usually less than 1 year can be achieved. In patients with much higher serum PSA levels, chemotherapy with carboplatin plus docetaxel should be considered.

[Urethral stricture : From diagnostics to appropriate treatment]. / Urethrastriktur : Von der Diagnostik bis zur sinnvollen Therapie.

Before making a treatment decision for patients presenting with a urethral stricture, following anamnesis and general examinations, appropriate diagnostics are necessary. This includes at least uroflowmetry and cystourethrography and the use of ultrasound and cystoscopy may be of additional help. The curative treatment of a urethral stricture is always an operation. Besides endourological procedures, open surgery for urethral reconstruction is also performed. This article aims to give an overview about the necessary diagnostic measures and the pros and cons of the different operative therapies.

[Urinary tract infections in children]. / Harnwegsinfekte bei Kindern.

Urinary tract infections (UTI) are the most common bacterial infections in children. The symptoms are not very specific and range from abdominal pain, poor feeding to nocturnal urinary incontinence. The technique of collecting urine plays an important role for securing the diagnosis. The best way to obtain urine in non-toilet-trained children is catheterization or suprapubic bladder aspiration. In toilet-trained children midstream urine is an acceptable alternative after cleaning the foreskin or labia. In the case of an infection a prompt empirical antibiotic therapy is necessary to reduce the risk of parenchymal scarring of the kidneys. There are different approaches to diagnose vesicoureteral reflux in different countries. The commonly used standard approach in Germany is voiding cystourethrography. In the case of reflux dimercaptosuccinic acid (DMSA) scintigraphy should be performed additionally to exclude renal scarring (bottom-up approach).

[Localized intermediate- to high-risk prostate cancer]. / Lokal begrenztes Intermediate- bis High-risk-Prostatakarzinom.

BACKGROUND: National and international guidelines recommend radical prostatectomy (RP) and radiotherapy (EBRT) as standard treatment for intermediate- and high-risk prostate cancer. Survival benefit of RP in prostate cancer has been proven in prospectively randomized trials. In contrast, the benefit of EBRT as well as the direct comparison of EBRT and RP have been investigated in several retrospective analyses, but are limited by typical problems associated with retrospective studies. RESULTS: Most of the studies comparing RP with EBRT favor RP with regard to overall survival and cancer-specific survival. Especially in young patients with high-grade prostate cancer, RP seems to be superior in comparison with EBRT. These patient are at high risk of a PSA recurrence and subsequently need an additional radiotherapy. Mortality and morbidity related to these both methods are low. Main complications of RP are urinary incontinence and erectile dysfunction. In contrast, rectal sequelae, erectile dysfunction, and irritative urinary symptoms are the main cause for postinterventional morbidity in patients after EBRT.

[Vesico-ureteral reflux: Diagnosis and treatment recommendations]. / Vesikoureteraler Reflux : Diagnose und Therapieempfehlungen.

BACKGROUND: Vesico-ureteral reflux (VUR) is one of the most common urologic diseases in childhood. About every third child that presents with a urinary tract infection (UTI) has urinary reflux to the ureter or kidney. Demonstration of a backflow of urine into the ureters or kidneys proves vesicoureteral reflux. In unclear cases, a positioned instillation of contrast agent (PIC) cystogram might be performed and is able to prove vesico-ureteral reflux. OBJECTIVES: Since low-grade VUR has a high probability of maturation and self-limitation, infants with VUR should be given prophylactic antibiotics during their first year of life, reevaluating the status of VUR after 12 months. The aim of any treatment is to prevent renal damage. THERAPY: The individual risk of renal scarring is decisive for the choice of adequate therapy. This risk is mainly dependent on reflux grade, age, and gender of the child as well as parental therapy adherence. In principle, therapeutic options include conservative as well as endoscopic or open surgical antireflux therapies. CONCLUSION: Decisions on treatment should be made individually with parents taking into account all the findings available.

[Scrotal space-occupying lesions]. / Skrotale Raumforderungen.

Palpable scrotal masses are common scenarios in any clinical practice. These tumors can be painful or painless, can be intratesticular or extratesticular and be cystic or solid. The distinction between benign and malignant tumors is of utmost importance to enable an adequate and differentiated therapy of patients. In clinical diagnostics besides the medical history, examination of the inguinoscrotal region, laboratory diagnostics and ultrasound examination of the inguinoscrotal area play a decisive role. During the last few years the increased use of contrast-enhanced ultrasound has helped clinicians in differentiating scrotal tumors. Malignant tumors are of particular importance because this entity is the most frequent malignant disease among younger men and according to the Robert Koch Institute there are approximately 3900 new patients in Germany each year (Robert Koch Institute, Krebs in Deutschland 2007/2008 and 2012).

[Organ and function preservation in urethral cancer]. / Organ- und Funktionserhalt beim Urethralkarzinom.

Primary urethral carcinomas are rare tumors that can occur both in men and women. Histological patterns of these tumors are mixed, urothelial tumors occur as well as squamous cell tumors or adenocarcinomas.There are different clinical factors that define clinical prognosis, and the 1- and 5-year cancer-free survival is 75% and 54%. Therapy of locally limited disease is surgical resection, and organ-preserving treatment is possible if negative frozen sections prove complete surgical resection. However, in men a perineal urethrostomy might be necessary, and in women there is a high risk of urinary incontinence if more than 2 cm of the distal urethra is resected.In case of locally advanced tumors or tumors of the proximal urethra, a radical urethrectomy with supravesical urinrary diversion is necessary. In some cases neoadjuvant (radio-)chemotherapy may be an option.

[Urine marker systems for diagnosis of urothelial cancer]. / Urinmarkersysteme zur Diagnostik des Urothelkarzinoms.

Cystoscopy and urinary cytology are standard tools in the diagnostics of urothelial cancer of the urinary bladder; however, cystoscopy is invasive and urinary cytology lacks accuracy for the diagnosis of low grade tumors. More recently several alternative urinary test systems were developed with the aim to make the diagnostics of urothelial tumors more reliable; however, in general all protein-based point of care test systems have a high rate of false positive test results, especially in patients with benign disorders. Fluorescence in situ hybridization, which is highly sensitive and specific, may be a reasonable supplement to the diagnostic spectrum in patients after instillation therapy or bladder replacement. Additionally, there are several new test systems which still need to be tested in large clinical studies with respect to diagnostic accuracy.

[Prepuce as free transplant]. / Präputialhaut als freies Transplantat.

Graft urethroplasty using free transplants has become a standard procedure in the therapy of complicated urethral strictures. Various types of tissues can be used as graft material and different criteria are important for the suitability of tissues for urethroplasty. It was recognized early on that the prepuce was an easy to harvest tissue with low morbidity and excellent functional results. In this article the suitability of this tissue for functional results will be discussed within the context of the biology of free transplants and the available literature.

[Management of urethral strictures: practical guidelines]. / Management von Harnröhrenstrikturen : Ein praktischer Leitfaden.

For the diagnosis of urethral strictures it is of utmost importance to determine the exact position and length of the strictured area. The optimal method for this purpose is retrograde urethrography which can be combined with a voiding cystourethrography. Endoscopic treatment of urethral strictures is only reasonable for cases with short segment bulbar strictures (<1.5 cm) otherwise recurrence rates are very high. For long segment or recurrent strictures only open urethroplasty provides good results in terms of recurrence-free survival. In these open techniques care must be taken in early postoperative management to obtain the best results.

[Etiology and pathophysiology of benign prostate hyperplasia]. / Ätiologie und Pathophysiologie der benignen Prostatahyperplasie.

The pathogenesis of benign prostate hyperplasia (BPH) is still unclear. It is a common disease affecting exclusively humans in its full clinical appearance. There is a broad variety of possible underlying mechanisms which most likely interact in the pathogenesis of the disease: inflammatory processes taking place predominantly in the stroma and inducing proliferation of all tissues within the transitional zone, an imbalance of androgens and estrogens and their receptors, hyperinsulinemia and hypercholesterolemia (metabolic syndrome) as direct promoters of glandular growth and autosomal dominant inheritance. The detrusor muscle responds to the increased outflow resistance with muscular hypertrophy. Decreased compliance of the bladder wall results in voiding difficulties while electric instability of the hypertrophied detrusor muscle and increased recruiting of otherwise silent afferent fibres cause storage symptoms.