Recurrent aggressive angiomyxoma of the urinary bladder. Case report and review of the literature.

Aggressive angiomyxoma is a rare neoplasm which predominantly involves the female pelvis and perineum. Forty-four cases have been reported in the world literature, including 10 cases in men. To the best of our knowledge, the first case of recurrent aggressive angiomyxoma of the urinary bladder is presented here. Operative management, radiologic features and pathological findings are discussed.

[Lymph node staging of bladder neck carcinoma with positron emission tomography]. / Das Lymphknotenstaging des Harnblasenkarzinoms mit der Positronenemissionstomographie.

PET is a new method in nuclear medicine which examines the metabolism and not the morphology. Tumors show a higher rate of glycolysis than benign tissue and hence can be detected by radioactive glucose. This method has proved good for various tumors. In this study the lymph node staging of bladder cancer by PET was investigated. In 64 patients a PET of the pelvis after injection of fluorodeoxyglucose (FDG) was carried out preoperatively; the PET-results were compared with the histology of the OR specimen after classical pelvic lymphadenectomy. For lymph node staging positive nodes were found in 14 patients which was correct; a false-negative result was obtained in 7 patients. In 37 patients the PET-result was true-negative and in 6 patients false-positive resulting in a sensitivity of 67%, a specificity of 86% and an accuracy of 80%. Therefore, our PET results are encouraging and seem to be better than those obtained by classical staging procedures such as CT or MRI.

Virtual cystoscopy based on helical CT scan datasets: perspectives and limitations.

The purpose of the study was to simulate cystoscopy based on three-dimensional helical CT scan datasets in real-time in patients with tumours of the urinary bladder. A helical CT scan with double detector technology was carried out pre-operatively in 11 patients with histologically confirmed carcinoma of the urinary bladder and one patient with chronic cystitis. A non-enhanced scan was first performed, followed by an examination in the early phase of contrast medium enhancement. Further images were acquired after adequate filling of the bladder with contrast medium, approximately 30 min after injection. These data were transferred to a separate graphic computer workstation and reconstructed. The results were then compared with the cystoscopic and histopathological findings. All tumours of the urinary bladder identified at fibreoptic cystoscopy were shown on virtual cystoscopy. The best reconstruction results were obtained from data acquired 30 min after injection of contrast medium. The ureteric orifices were not visualized at virtual cystoscopy. These data lead us to conclude that, at present, virtual cystoscopy has not reached the quality of fibreoptic examination and remains restricted to use in specific cases, for example patients with urethral strictures.

Treatment of high-risk patients with subvesical obstruction from advanced prostatic carcinoma using a thermosensitive mesh stent.

OBJECTIVE: To evaluate the results obtained using a permanent prostatic stent system (Memotherm, Bard/ Angiomed, Karlsruhe, Germany) in high-risk patients with advanced prostatic carcinoma and subvesical obstruction. PATIENTS AND METHODS: The study included 35 patients (mean age 75.3 years, range 53-89) with advanced prostatic carcinoma and persistent subvesical obstruction despite androgen ablation. Because of serious concurrent diseases, 49% of these patients were classified as American Society of Anesthesiologists (ASA) grade 3 and 51% as ASA grade 4. The patients were treated using the Memotherm stent, a thermosensitive Nitinol mesh stent. The outcome was assessed by measuring voiding variables, a symptom score and as the incidence of complications. RESULTS: After inserting the stent, 33 (94%) of the patients were able to void spontaneously and there was a statistically significant improvement in the voiding variables. These results remained unchanged over a mean (range) follow-up of 15.2 months (3-38). There were no serious complications arising from the insertion of the stent. CONCLUSION: For high-risk patients with subvesical obstruction caused by prostatic carcinoma, the insertion of a permanent metal stent system offers a useful alternative treatment to transurethral resection.

[Is retrograde ureteropyelography necessary before kidney pelvis-plasty in childhood?]. / Ist die retrograde Ureteropyelographie vor einer Nierenbeckenplastik im Kindesalter erforderlich?

For routine evaluation of ureteropelvic junction obstruction in children, sonography, voiding cystogram, IV pyelogram and a renal scan in combination with administration of furosemide are available. Furthermore, often preoperative antegrade or retrograde ureteropyelography is performed. However, the significance of retrograde ureteropyelography in the world literature remains controversial. Therefore, we reviewed the records of 41 children who underwent a pyeloplasty in our department. In 9 children the ureter was visualized by IV pyelogram, voiding cystogram or antegrade ureteropyelography; a retrograde examination of the ureter was performed in 21 children before pyeloplasty in the OR. In 11 children the ureter was not visualized preoperatively. Retrograde ureterography neither gave additional information in any patient nor did it change the operative technique. In the children where the ureter was not visualized preoperatively, no ureteric abnormality was found in association with ureteropelvic junction obstruction. Hence, we conclude that retrograde ureteropyelography before pyeloplasty in children is not necessary, provided that sonography does not show ureteral dilatation.

[Radiation exposure in digital micturition cystourethrography in children. How much exposure by fluoroscopy?]. / Strahlenbelastung bei der digitalen Miktionszysturethrographie bei Kindern. Welchen Anteil hat die Durchleuchtung?

OBJECTIVE: Determination of the proportion of the dose-area product caused by fluoroscopy at voiding cystourethrography in children, using digital image intensifier technology. PATIENTS AND METHODS: Using computer-assisted dosimetry, we determined the dose-area product and the respective proportions of the dose-area product caused by fluoroscopy and radiography as well as the number of radiographs taken at a given examination of 40 children (8 children less than 2 years old, 15 children between 2 and 6 years old and 17 children between 6 and 15 years old). RESULTS: The computer software program correctly differentiated between fluoroscopy and radiography in 80% of cases. Incorrect results were primarily observed in newborns and young children. The total radiation dose ranged in relation to patient age from 22 to 651 cGy x cm2. Fluoroscopy was responsible for an average 78% of the applied radiation dose. CONCLUSION: Computer-assisted dosimetry is useful in determining the proportion of the dose-area product caused by fluoroscopy in older children undergoing voiding cystourethrography. When image intensifier technology is used, this accounts for more than 75% of the total radiation dose. The method is not suitable for use in small children.

[The diuresis urogram in patients with a bladder replacement]. / Das Diureseurogramm bei Patienten mit Harnblasenersatz.

PURPOSE: To differentiate between urodynamically relevant obstruction and functionally unimportant dilation of the upper urinary tract in patients with neobladder using a modified furosemide urogram. METHOD: An excretory urogram with furosemide loading was carried out in 19 patients with neobladder and sonographically and urographically confirmed dilation of the upper urinary tract. Once strong contrasting of the renal pelves and calyces has been achieved, 20 mg of furosemide were applied and late radiographs were obtained at 15 min and 30 min, respectively. An obstruction was defined as increasing dilation of the renal pelves and calices during forced diuresis and lack of washout effect of the contrast medium. RESULTS: In 32 cases, the renoureteral unit (RUU) was dilated on ultrasound. Of these, 25 RUU's showed good emptiness of contrast medium upon stimulation of diuresis, six RUU's returned a borderline findings, while one RUU was found to exhibit a decompensated anastomotic stenosis, which was dilated. Two further patients with borderline findings were later treated surgically due to their pain symptoms. No patient required further preoperative diagnostic procedures. CONCLUSIONS: The modified furosemide urogram represents a cost-effective diagnostic orientation strategy in patients with neobladder and dilated renal pelves and calyces and is both well-tolerated by patients and meets with broad acceptance from the urologic staff.

Dynamic fluorescence changes during photodynamic therapy in vivo and in vitro of hydrophilic A1(III) phthalocyanine tetrasulphonate and lipophilic Zn(II) phthalocyanine administered in liposomes.

The fluorescence emission of hydrophilic tetrasulphonated aluminium phthalocyanine (AlPcS4) and hydrophobic zinc phthalocyanine (ZnPc), bound to the membrane of liposomes, was investigated in vivo in an appropriate tumour model of the rat bladder and in RR 1022 epithelial cells of the rat. The sensitizers were administered systemically to the rats and photodynamic therapy (PDT) was performed 24 h later. During PDT treatment, the fluorescence was measured every 30 s. The fluorescence was excited with 633 nm light from an HeNe laser and the fluorescence spectra were detected with an optical multichannel analyser system. PDT was performed for both sensitizers using 672 nm light from an Ar+ dye laser. The fluorescence changes during PDT were significantly different for the two phthalocyanines. For AlPcS4, an initial fluorescence intensity increase, followed by subsequent photobleaching, was observed. In contrast, ZnPc fluorescence showed an exponential decrease and no increase at the start of treatment. Tumour necrosis 24 h after PDT was significant only for ZnPc. RR 1022 cells incubated for 24 h with AlPcS4 revealed a granular fluorescence pattern, whereas ZnPc was localized diffusely in the cytoplasm of the cells. In agreement with the in vivo measurements, subcellular relocalization and a fluorescence intensity increase were detected exclusively in the case of AlPcS4. Morphological changes at this time were significant only for ZnPc. The subcellular localization and fluorescence kinetics were obtained using a confocal laser scanning microscope.

[Positron emission tomography in diagnosis of renal cell carcinoma]. / Die Positronenemissionstomographie zur Diagnostik des Nierenzellkarzinoms.

PET is a new method for staging malignant tumors; the metabolism is examined and not the morphology. In this study the staging of renal cell carcinoma (RCC) by PET was investigated. In 29 patients PET with fluorodeoxyglucose (FDG) was carried out preoperatively; the PET results were compared to the histology of the OR specimen. In 26 patients a RCC was found histologically, which was diagnosed correctly by PET in 20 patients; in 6 patients a false-negative PET result was obtained. An angiomyolipoma, a pericytoma and a pheochromocytoma showed a false-positive PET result. For lymph-node staging positive nodes were found in 3 patients which was correct; no false-negative result was obtained. In 25 patients the PET result was true-positive; once a false-positive finding occurred. In conclusion, PET offers the advantage that no allergy to FDG is known and a pacemaker or metal implants are not contraindications; in diagnosing RCC, according to our results there is no further advantage of FDG-PET in comparison to standard methods; for lymph-node staging the results are equivalent

Aminolevulinic acid for photodynamic therapy of bladder carcinoma cells.

A new concept in photosensitizing tumor cells is photosensitizer synthesis in situ. Aminolevulinic acid (ALA) is a precursor of protoporphyrin IX (PP IX), a potent photosensitizer. The goal of our study was to examine dark toxicity, phototoxic potential, metabolism of ALA and morphological alterations in Waf bladder cancer cells. Dark toxicity of Waf cells was observed after incubation with ALA, beginning at a concentration of 15 mM. Photodynamic treatment with ALA at concentrations of 1, 5 and 10 mM showed a drug- and light-dose-dependent cell survival rate in comparison to a control group. Two incubation times of 3.5 and 5.5 h were compared for cell survival. After a longer incubation time of 5.5 h, cell survival was decreased in all experiments; this is consistent with our extraction data where higher fluorescence was found after 5.5 than after 3.5 h. The results show that ALA-induced photosensitization has a high potential for photodynamic therapy (PDT) of superficial bladder carcinoma.

Biodistribution and phototoxicity of 5-aminolevulinic acid-induced PpIX in an orthotopic rat bladder tumor model.

5-Aminolevulinic acid (ALA) is a precursor of heme biosynthesis. In the penultimate step of this biosynthesis, protoporphyrin IX (PpIX), an effective photosensitizer, is generated. In this study, the biodistribution and photodynamic effect of ALA-induced PpIX were investigated in an orthotopic rat bladder tumor model. A quantitative comparison of PpIX biodistribution by extraction and fluorescence spectroscopy following intravenous and intravesical administration of ALA was made. The tumor to normal bladder wall ratio was 2:1 at 4 hours for both delivery modes. Fluorescence microscopy demonstrated predominantly cellular rather than stromal PpIX fluorescence. Phototoxicity, evaluated 4 hours after ALA administration, was light dose-dependent with the most efficient tumor necrosis being observed upon 150 J/cm.2 of 630 nm. irradiation. These data suggest that optimized photodynamic therapy with ALA-induced PpIX may be an alternative treatment for superficial bladder carcinoma.

[Positron emission tomography. Introduction of a new procedure in diagnosis of urologic tumors and initial clinical results]. / Positronenemissionstomographie. Einführung eines neuen Verfahrens in die Diagnostik urologischer Tumoren und erste klinische Ergebnisse.

Correct preoperative staging of malignant tumors is a prerequisite for an adequate therapy. This is not always possible with the imaging techniques available. Often, only an exploratory laparotomy can give the final diagnosis. Therefore, the search is on for a non-invasive technique for staging. Positron emission tomography (PET) is a new method in nuclear medicine; it is used for the diagnosis of primary tumors, for staging, and for follow-up after therapy. With PET, biochemical pathways and physiological functions are studied, in contrast to CT and MRI, with which anatomy and morphology are examined. In our department PET was used in 26 patients with invasive bladder cancer, in 11 patients with renal cell carcinoma and in 1 patient for follow-up after testicular cancer. The primary bladder tumor was found in 85% of cases; in 4 a non-organ-confined tumor was diagnosed preoperatively. Specificity in staging of lymph nodes was 86% (18/21); in 3 patients lymph nodes were false-positive on PET. However, in 5 patients all lymph node metastases were found by PET. Renal cell carcinoma were found in 8 out of 9 patients; in 2 patients with high-grade tumors an FDG-uptake defect was found. Lymph node staging was accurate in 9 patients without metastases and in 2 with metastases. One patient had a slightly enlarged retroperitoneal lymph node in the follow-up of a non-seminomatous germ cell tumor, which was positive on PET. Histology confirmed that it was the only positive lymph node within the whole specimen after retroperitoneal lymphadenectomy. PET gives new insights in uro-oncology by examination of the metabolism. Our initial results are promising and warrant further studies.

Minimal invasive therapy of prostatic abscess by transrectal ultrasound-guided perineal drainage.

Prostatic abscess is a rare but severe disease. Conventional therapy is transurethral resection of the prostatic abscess. Since the advent of transrectal ultrasound (TRUS) a minimal-invasive treatment of prostatic abscess by TRUS-guided perineal drainage under local anesthesia is available. We report on our experience in 6 patients with prostatic abscess. TRUS is a simple, rapid, easily accessible, and accurate method for diagnosis, therapy and follow-up of a prostatic abscess. TRUS-guided perineal drainage of a prostatic abscess is an effective, minimal-invasive and cost-effective treatment without adverse side effects.

Photodynamic efficiency of liposome-administered tetramethyl hematoporphyrin in two human bladder cancer cell lines.

The main problems presented by superficial bladder carcinoma, its high recurrence rate and multifocal appearance, require treatment of the bladder as a whole. Photodynamic therapy (PDT) is one such experimental treatment for superficial bladder carcinoma, involving the administration of a photosensitizer that accumulates in the tumor tissue, and subsequent irradiation of the tumor with light. Since the photosensitizers used in PDT suffer from several drawbacks, new photosensitizers are being sought. Drug delivery systems are also being investigated for the administration of hydrophobic photosensitizers and enhancement of photodynamic efficiency and tumor selectivity. In this study we examined a new photosensitizer, tetramethyl hematoporphyrin (TMHP), in two human bladder cancer cell lines. In the first pair of the experiments, TMHP was bound to unilamellar liposomes. Cellular uptake, dark toxicity and photodynamic efficiency were then studied. Fluorescence microscopy showed TMHP localization in the cytoplasm in a perinuclear region, sparing the nucleus. Dark toxicity occurred after incubation of cells with TMHP above a concentration of 20 micrograms/ml. Irradiation was carried out using an argon-pumped dye laser emitting a wavelength of 630 nm at a fluence of 3.6 and 7.2 J/cm2. Before irradiation, cells were incubated with TMHP at concentrations of 2.5 and 5 micrograms/ml for 1 h. Cell survival rates after incubation with 5 micrograms/ml TMHP and irradiation at 7.2 J/cm2 were 15.7% of control cells for Rec and 4.5% for Waf cells. Uptake studies showed a higher intracellular TMHP concentration in Waf than in Rec cells. This correlates with the higher PDT efficiency seen in Waf cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of two routes of photosensitizer administration for photodynamic therapy of bladder cancer.

Photodynamic therapy (PDT) consists in administration of a photosensitizer and subsequent irradiation of the tumor with visible light. Routinely the photosensitizer is given intravenously (i.v.). The goal of our study was to examine whether intravesical (i.b.) instillation of the photosensitizer for PDT of bladder cancer might be feasible. Therefore, the uptake of chlor-aluminum-sulfonated phthalocyanine (CASPc) in bladder, bladder tumor, skin, and muscle in a rat bladder cancer model after i.v. injection and i.b. instillation was compared. The efficacy of PDT after either method of administration was also evaluated. The CASPc concentration in bladder tumor after i.v. injection was approximately 1.5-fold that after i.b. instillation. The ratio of CASPc concentration between bladder tumor and normal bladder was approximately 2:1 after administration by either route. There was no systemic absorption of CASPc after i.b. instillation; hence no systemic side effects are expected. PDT showed similar effects on bladder tumor after either method of administration, but less side effects on normal bladder wall after i.b. instillation. Our results demonstrate that i.b. instillation of CASPc for PDT of superficial bladder cancer seems to have advantages over i.v. injection.

Juvenile xanthogranuloma of the penis.

Although juvenile xanthogranulomas are frequently seen by pediatricians and dermatologists, urological data are extremely rare. To our knowledge we report the first case of juvenile xanthogranuloma of the penis. Differentiation from other, similar lesions with more ominous prognostic significance, such as xanthosarcoma, malignant fibrous histiocytoma or histiocytic reticulosarcoma, is essential. This well documented case is noteworthy, since proper ad hoc diagnosis would have allowed us to perform a small biopsy rather than 2 surgical procedures. Our data support the currently held belief that juvenile xanthogranulomas are generally benign, self-limiting lesions.