Prognostic significance of Fuhrman grade and age for cancer-specific and overall survival in patients with papillary renal cell carcinoma: results of an international multi-institutional study on 2189 patients.

PURPOSE: Because the prognostic impact of the clinical and pathological features on cancer-specific survival (CSS) and overall survival (OS) in patients with papillary renal cell carcinoma (papRCC) is still controversial, we want to assess the impact of clinicopathological features, including Fuhrman grade and age, on survival in surgically treated papRCC patients in a large multi-institutional series. METHODS: We established a comprehensive multi-institutional database of surgically treated papRCC patients. Histopathological data collected from 2189 patients with papRCC after radical nephrectomy or nephron-sparing surgery were pooled from 18 centres in Europe and North America. OS and CSS probabilities were estimated using the Kaplan-Meier method. Multivariable competing risks analyses were used to assess the impact of Fuhrman grade (FG1-FG4) and age groups (<50 years, 50-75 years, >75 years) on cancer-specific mortality (CSM). RESULTS: CSS and OS rates for patients were 89 and 81% at 3 years, 86 and 75% at 5 years and 78 and 41% at 10 years after surgery, respectively. CSM differed significantly between FG 3 (hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.17-8.22; p < 0.001) and FG 4 (HR 8.93, 95% CI 4.25-18.79; p < 0.001) in comparison to FG 1. CSM was significantly worse in patients aged >75 (HR 2.85, 95% CI 2.06-3.95; p < 0.001) compared to <50 years. CONCLUSIONS: FG is a strong prognostic factor for CSS in papRCC patients. In addition, patients older than 75 have worse CSM than patients younger than 50 years. These findings should be considered for clinical decision making.

Mucin-Poor Mucinous Tubular and Spindle Cell Carcinoma of the Kidney Presented with Multiple Metastases Two Years after Nephrectomy: An Atypical Behaviour of a Rare, Indolent Tumour.

BACKGROUND: Mucinous tubular and spindle cell carcinoma (MTSCC) is a rare type of renal cell carcinoma, whose clinical behaviour and metastatic potential have not been fully elucidated to date. There are only a few metastatic cases in the literature, which all either featured sarcomatoid differentiation or were synchronously metastasised at diagnosis. CASE PRESENTATION: We report a case of a 49-year-old male with end-stage kidney disease on dialysis, presenting with multiple osseous metastases of a mucin-poor variant of MTSCC of the kidney, without sarcomatoid differentiation, two years after bilateral nephrectomy for papillary renal cell carcinoma (RCC) at a curable stage. After retrospectively reexamining the initial nephrectomy specimens, the tumour of the right kidney was also diagnosed as a mucin-poor variant of MTSCC, while the tumour of the left kidney was confirmed as a papillary RCC. CONCLUSIONS: It is proposed that MTSCC can be associated with end-stage renal disease and that particularly the mucin-poor variant is easily confused with papillary renal cell carcinoma, as happened in this case. Although it is considered as a relatively indolent malign entity, it can metastasise even years after successful primary surgical treatment. This implies, besides accurate diagnosis, that MTSCC patients should be monitored closely in the follow-up period.

[Abdominal organ retrieval: strategies to improve quality]. / Viszerale Organexplantation: Maßnahmen zur Verbesserung der Qualität.

The blatant problem of organ shortage leads to an increasing acceptance of organs from extended criteria donors. This increases the importance of the process of organ donation and retrieval. A working group of representatives of Bavarian retrieval surgeons and the procurement organization German Foundation of Organ Transplantation (DSO) was initiated to develop consensus-based recommendations for quality improvements in the field of organ retrieval on the basis of regional data. The main aim was to professionalize retrieval teams by specified training standards and to define objective qualifications for retrieval surgeons. Initial measures of the working group included agreement on standardized retrieval techniques and improvement of documentation in terms of quality forms and the return rate of the forms. Quality data are being analyzed prospectively with a new categorization of complications. Communication among centers and teams and complication reporting has already been improved and initial structural changes have been set up.

[Use of bowel segments for ureter reconstruction]. / Harnleiterersatz unter Verwendung von Darmsegmenten.

When ureter damage is extensive or affects the midureter continuity can be restored using bowel segments. The principle issues of these techniques comprise reconstruction of the urinary tract preserving renal function in a long-term setting. The safety of ureters reconstructed from bowel segments has been validated in several large series as a reliable last resort solution with favorable results and low complication rates. Ureter reconstruction with bowel segments is doomed to fail in patients with short-bowel syndrome or Crohn's disease. Furthermore, the applicability in children and patients with progressive renal deficiency is severely limited. To prevent renal deterioration the use of retubularized bowel segments as a substitute for ureter defects has been postulated. Whereas antirefluxive implantation seems unnecessary in patients with a native bladder in situ or orthotopic bladder substitution, it is recommended in continent bowel reservoirs with cutaneous stoma.

[Insufficiency of the efferent segment in continent cutaneous diversion]. / Das inkompetente Nabelstoma.

Besides common requirements like universal applicability, reproducibility, and low complication rate, functionality and cosmetic aspects are essential in continent cutaneous diversions. Creation of the continence mechanism certainly represents the major surgical challenge in continent cutaneous diversions. Complete continence and ease of catheterization are mandatory for the patient's quality of life.High surgical competence, creativity, and variability are required in cases of revisional surgery for stomal insufficiency. In addition to accurate preoperative clinical, endoscopic, and radiologic evaluation, extensive expertise in the fields of continent urinary diversion and reconstructive urology allows performance of a surgical solution ideally adapted to the patient's individual situation. Between January 1990 and September 2011 we performed urinary diversion in 1,224 patients (mean follow-up 90.3 months). Continent urinary diversion was performed in 717 patients (59%); in 486 patients an ileocecal reservoir with continent cutaneous diversion, in 186 patients an ileocecal neobladder, and in 45 patients a sigma rectum pouch was created. Incontinence rate and stenosis rate in patients with appendico-umbilical stoma (n=219) were 2.3% and 10% and in patients with intussuscepted ileum nipple (n=267) nipple 5.2% and 2.7%. Stenosis usually can be corrected easily by simple excision of the obstructive scarred tissue or by stomal reconfiguration. Outlet failure may result from simple causes like fistula formation between reservoir and efferent segment or skin and nipple gliding or prolapse which can easily be repaired. More complex situations might require creation of a secondary continence mechanism. In our series of 486 patients having undergone continent cutaneous diversion in our department, 14 patients (appendico-umbilical stoma n=5, ileal nipple n=9) suffered from irreversible damage of the continent outlet. In 11 patients creation of a secondary intussuscepted ileal nipple and in 3 patients a modified Managadze procedure was performed.In case of absence of the ileocecal valve (e.g. in primary ileal reservoirs, ileocolonic reservoirs without integrated ileocecal valve) and in case of a preexisting pouch of small capacity we prefer augmentation of the primary reservoirs with an ileocecal cup patch plasty in combination with the submucosally embedded appendix or intussuscepted ileal nipple serving as continent outlet. In our institution this was done in four patients who had undergone primary surgery elsewhere.

[Secondary malignancies in urinary diversions]. / Sekundärmalignome in Harnableitungen.

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

[The role of PSA in diagnosis of prostate cancer and its recurrence]. / Stellenwert des prostataspezifischen Antigens (PSA) in der Primär- und Rezidivdiagnostik des Prostatakarzinoms.

Prostate specific antigen is the most important tumor marker of prostate cancer. PSA, in conjunction with digital rectal examination, is the first-line clinical tool for detection of prostate cancer. To improve its specificity PSA-density, PSA-ratio (fPSA/tPSA), PSA-velocity, and complexed PSA have been introduced into clinical praxis. The treatment of lower stage disease in younger men has resulted in a longer period of post-treatment cancer surveillance. Biochemical recurrence is an early indicator for clinical disease recurrence. PSA doubling time allows to distinguish between local and systemic progression and is also a valid predictor for distant metastasis and death of disease.