Risk of biochemical recurrence in patients with a positive surgical margin after radical prostatectomy.

INTRODUCTION: Serum prostate specific antigen (PSA) is an irreplaceable marker in the detection and follow-up of patients with prostate cancer. In our analysis we addressed factors that could indicate the likelihood of biochemical recurrence (BCR) early after radical prostatectomy. We mainly focused on the positive surgical margin (R1). METHODS: Retrospective evaluation and analysis of the database of patients with prostate cancer after radical prostatectomy from 2001 to 2019. In total 1529 patients were enrolled in the study. The median follow-up was 48 months. The age of the patients ranged from 49 to 76 years. We used pre-operative PSA values, and the monitoring of the dynamics of 3rd generation PSA progression (detection limit 0.003 ng/ml) at month 1 and month 3 after surgery and then in 3-month intervals. We monitored the surgical margin positivity (R0 negative, R1 positive) and the Gleason score (GS) based on histological samples and we analysed the relationship to biochemical recurrence of the disease. RESULTS: The pre-operative PSA value did not show a direct relationship to the R1 risk. Patient values in the groups R1 and R0 differed only by 1.159 ng/ml (p=NS). The 3rd generation PSA value at month 1 after surgery was 50.82% higher in R1 patients (p>0.001). 50% of patients with R1 (29.5% patients of the total) did develop BCR during the follow-up period, while in patients with R0 (70.5% patients of the total) this proportion was 30% (p>0.001). Among those with GS 67, 47% developed BCR. The GS 810 group relapsed in 75% of the cases (p>0.001). CONCLUSION: According to our analysis 33% of the patients reached the stage of biochemical recurrence. We demonstrated a direct dependency between the risk of recurrence and the final Gleason score. The presence of R1 should not be viewed as a direct indication for adjuvant radiotherapy.

Sulcus nervi dorsalis penis: site of origin of Alcock's syndrome in bicycle riders?

This article introduces a hypothesis that the pudendal nerve compression syndrome, also known as the Alcock's syndrome in long-time duration bicycle riders might be caused by an irritation of the dorsal nerve of penis in a groove on the inferior ramus and the anterior surface of pubis, previously described by authors as the sulcus nervi dorsalis penis. Alcock's syndrome in bicycle riders has been characterized as a prolonged glans and penile insensitivity, genital numbness and an erectile dysfunction. Although no anorectal pain or disturbance of the bulbocavernosus reflex has been reported in these patients, we assume it cannot be caused by a compression of the pudendal nerve in pudendal (Alcock's) canal, hence by a compression of the dorsal nerve of penis in the sulcus nervi dorsalis penis. In future, if clinical studies confirm our hypothesis, it might be more sophisticated to evaluate this syndrome apart from the Alcock's syndrome and term it the dorsal nerve compression syndrome rather than the Alcock's syndrome.

Sulcus nervi dorsalis penis/clitoridis: its reliability as a character for sex determination of isolated human pubic bones.

This study describes a distinct groove on the caudal and ventral surfaces of the pubic bone termed the "sulcus nervi dorsalis penis/clitoridis" and assesses its usefulness as a character for sex determination of isolated pubic bones. Analysis of 168 male and 118 female pubic bones showed that the presence of a sulcus was a non-random event. A sulcus was present in 72% of male pubic bones and 83% of female pubic bones examined (Czech population). Seven characters (including three of the sulcus) were measured in a sample of an 86 isolated pelvises grouped according to the gender. A step-wise discriminant function analysis was performed on this dataset to assess whether a combination of these characters could be used for gender identification of isolated pubic bones. A bivariate plot using Mahalanobis distances showed distinct differences in male and female pubic bones. The width of the sulcus and the craniocaudal length of the pubic symphysis significantly described most of the variations observed between male and female pelvises. A post hoc analysis of the reliability of the technique showed that stepwise discriminant function correctly identified 83% of male and 86% of female known-sex pelves. Thus discriminant function analysis of the sulcus and pubic bones can reliably be used to determine sex in human osseal remnants.

[Sulcus nervi dorsalis penis/clitoridis: clinical and forensic aspects]. / Sulcus nervi dorsalis penis/clitoridis: klinické a forenzní aspekty.

Sulcus nervi dorsalis penis/clitoridis is a groove on inferior ramus of pubis and ventral surface of the body of pubis, where dorsal nerve of penis in male and dorsal nerve and artery of clitoris in female run. Close relation of the dorsal nerve of penis/clitoris and pubis, represented by the course of sulcus nervi dorsalis penis/clitoridis has a major impact in surgical disciplines. Exact preparation of the dorsal nerve of penis is crucial in correct performance of conversion of genitalia in patients with transsexualism, in reconstruction of posterior urethra, in hypospadia, during performance of penile blockade during circumcision and in revascularization surgery of erectile dysfunction. The role of sulcus nervi dorsalis penis in the Alcock's syndrome is discussed. Similarly, it is advisable to take care of the dorsal nerve of clitoris inside sulcus nervi dorsalis clitoridis during reduction clitoridoplasty in patients with adrenogenital syndrome and during the insertion of transobturator vaginal tape. Injury of dorsal nerve of penis/clitoridis leads to hypestesia or anestesia of glans penis/clitoridis. The injury of dorsal artery of clitoris leads to hematoma. It is possible to use sulcus nervi dorsalis penis/clitoridis in sexing of isolated pubis from antropological or forensic purposes. Lateral border of sulcus nervi dorsalis penis/clitoridis corresponds to vertical ridge and lateral border of sulcus nervi dorsalis clitoridis to ventral arc--two parameters, which are part of the Phenice's method for sexing of isolated pubis.

[Tumoriform endometriosis of the urinary bladder in advanced pregnancy]. / Tumoriformní endometrióza mocového mechýre v pokrocilém tehotenství.

A case of tumoriform endometriosis of urinary bladder immitating a tumor of the bladder during the first pregnancy of a 25-year-old patient was successfully treated by partial cystectomy allowing continuation of the pregnancy, a normal term delivery and after 5 months a second pregnancy with term delivery.

[Endometriosis imitating bladder tumor in 2nd trimester of pregnancy]. / Endometrióa imitující nádor mocového mechýre ve II. trimestru tehotenství.

OBJECTIVE: Case presentation of bladder endometriosis during 2nd trimester imitating urinary bladder tumour. SETTING: Mother and Child Care Institute, Prague. III. Medical School of Charles University, Prague. CASE REPORT: 25-years old patient, 2nd trimester of first pregnancy. TREATMENT: Partial bladder cystectomy. RESULT: Complete recovery succeded by term delivery. CONCLUSION: Tumouriform endometriosis of urinary bladder successfully treated by partial cystectomy allowing normal term delivery.

Qualitative and quantitative detection of urinary human complement factor H-related protein (BTA stat and BTA TRAK) and fragments of cytokeratins 8, 18 (UBC rapid and UBC IRMA) as markers for transitional cell carcinoma of the bladder.

OBJECTIVE: To evaluate the role of BTA stat, BTA TRAK, UBC Rapid, UBC IRMA and voided urinary cytology in the detection of bladder transitional cell carcinoma (TCC). METHODS: The study included 78 patients with TCC of the bladder (group A), 62 patients with a history of bladder TCC without tumor recurrence at the time of examination (B, control group), 20 patients with other malignancy of the urinary tract (C), 38 patients with non-malignant urinary tract diseases (D), 10 patients with urinary tract infection (E) and 10 healthy volunteers (F). Except in group F, voided urine was collected before cystoscopy or cystectomy. RESULTS: The specificity and sensitivity in bladder cancer detection were 87.1 and 74.4%, respectively with BTA stat, 79.3 and 48.7%, respectively with UBC Rapid, 100 and 33.3%, respectively with cytology, 72.6 and 75.6%, respectively with BTA TRAK, 64.5 and 70.5%, respectively with UBC IRMA. CONCLUSIONS: The BTA stat and BTATRAK tests are superior to UBC Rapid, UBC IRMA and urinary cytology in detection of bladder TCC. In daily practice however cytology remains the best adjunct to cystoscopy because of its high sensitivity in Tis and 100% specificity. Cystoscopy cannot be replaced by any of evaluated methods.

Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors.

BACKGROUND: To the authors' knowledge, few data exist regarding the functional and oncologic outcome of pelvic tumors in women with urethra-sparing cystectomy and orthotopic urinary diversion to the urethra. PATIENTS AND METHODS: The combined data of 102 women age 28-79 (mean, 59 yrs) years who underwent a urethra-sparing cystectomy and orthotopic urinary diversion for either primary bladder cancer (96 patients), carcinoma of the uterine cervix (2 patients), carcinoma of the vagina (1 patient), primary fallopian tube carcinoma (1 patient), uterine sarcoma (1 patient), or rectal carcinoma (1 patient) were reviewed. The histology of the 96 primary bladder tumors was 81 transitional cell carcinomas (TCC), 8 adenocarcinomas, 5 squamous cell carcinomas, 1 small cell carcinoma, and 1 unclassified. Follow-up ranged from 1.5-100 months (mean, 26 mos; median, 24 mos). In all patients, the bladder neck and up to 1 cm in length of the adjacent urethra were removed with the bladder. An ileal orthotopic neobladder procedure was performed if staging biopsies of the bladder neck and intraoperative frozen section of the urethral margin revealed no tumor. RESULTS: There was no perioperative mortality, and an early and late complication rate requiring secondary intervention in 5 (5%) and 12 (12%) patients. With 88 of 102 patients alive and 83 of 102 patients disease free, a disease-specific survival of 74% and a disease-free survival of 63% was estimated at 5 years. No pelvic recurrence was seen in 81 patients with TCC. Three pelvic recurrences occurred, two tumors of the inner genitalia and one adenocarcinoma of the bladder, none of them in the area of the urethra or its supplying autonomic nerves. Daytime continence was 82%; nocturnal continence was 72%. Twelve (12%) patients were unable to empty their bladders completely and needed some form of catheterization. CONCLUSIONS: The functional and oncologic outcome of female patients with an orthotopic urinary diversion to a remnant urethra was found to be comparable to that found in large studies on males. An orthotopic neobladder proved to be an oncologically safe option for women with pelvic tumors and was found to provide quality of life when there was adherence to previously defined selection criteria.

Detection of drug-induced apoptosis and necrosis in human cervical carcinoma cells using 1H NMR spectroscopy.

Apoptosis and necrosis need to be differentiated in order to distinguish drug-induced cell death from spontaneous cell death due to hypoxia. The ability to differentiate between these two modes of cell death, especially at an early stage in the process, could have a significant impact on accessing the outcome of anticancer drug therapy in the clinic. Nuclear magnetic resonance spectroscopy was used to distinguish apoptosis from necrosis in human cervical carcinoma (HeLa) cells. Apoptosis was induced by treatment with the topoisomerase II inhibitor etoposide, whereas necrosis was induced by the use of ethacrynic acid or cytochalasin B. We found that the intensity of the methylene resonance increases significantly as early as 6 h after the onset of apoptosis, but that no such changes occur during necrosis. The spectral intensity ratio of the methylene to methyl resonances also shows a high correlation with the percentage of apoptotic cells in the sample (r2=0.965, P<0.003).

Causes and treatment of residual urine volume after orthotopic bladder replacement in women.

OBJECTIVES: Intact innervation of the female urethra is conditional for normal urination. In the past, urethrectomy was performed as part of cystectomy. After intense anatomical studies of the female pelvis, urethral-function-sparing cystectomy was developed. METHODS: Our clinical group consists of 41 female patients who were operated from 1993 to 1998 for bladder cancer, utilizing cystectomy with orthotopic bladder replacement. RESULTS: In 28 patients, complete daytime continence was restored and in 13 patients, daytime continence was socially satisfactory (1-2 pads were used due to mild stress incontinence). The drawback of orthotopic replacements in females is the frequent development of serious residual volume, which was seen in one third of the 41 patients. The functional results of orthotopic neobladders and therapy of residual urine volume were documented using urodynamic studies. CONCLUSIONS: Postvoiding residual volume may be caused by isolated dysfunction of the urethra and can be treated with clean intermittent self-catheterization or with alpha-blockers, which improve evacuation of the neobladder.

Surgical conversion of genitalia in transsexual patients.

OBJECTIVE: To describe the techniques and outcome of genital and urethral reconstructive surgery during gender conversion as part of the treatment of transsexuals. PATIENTS AND METHODS: From 1992 to 1999, 82 patients were surgically converted after previous sexual and hormonal therapy. Using the male genital tissue to create new female genitalia, and vice versa, 30 male and 52 female transsexuals were converted. For male-to-female transsexuals, the technique of penile skin inversion was used 29 times and sigmoidocolpoplasty five times (in one patient primarily and in four patients to correct inadequate neovaginal size after penile skin inversion). In female-to-male transsexuals, 28 meta-idoioplasties and seven neophalloplasties were performed using the groin skin-flap technique, with 42 breast reductions also included as a part of the therapy. RESULTS: Surgical gender reassignment of the male transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm. Depending on the technique used in the reverse conversion, the patient maintained the ability to attain orgasm, and in many cases had a satisfactory appearance of the neopenis, with the potential to void while standing. CONCLUSIONS: The morphological proportions of each patient vary, and the different shapes and sizes of the tissues can be used for plastic operations. Thus the modelling of each individual genital in transsexuals can be considered 'original'.

[Magnetic resonance imaging in the diagnosis of prostatic carcinoma]. / Prínos magnetické rezonance (MRI) v diagnostice karcinomu prostaty.

The standard diagnostic and staging evaluation of prostate cancer includes digital rectal examination, transrectal ultrasonography (TRUS), serum prostate-specific antigen (PSA) level measurement, abdominal pelvic CT and radionuclide bone scan. Magnetic resonance imaging (MRI) (especially endorectal magnetic resonance) opens new possibilities for diagnostic imaging of the prostate. It seems to be better for detecting seminal vesicle invasion. Unfortunately, sensitivity in evaluation of minor capsular and seminal penetration is low and differentiation between haemorrhage, chronic inflammatory, fibrotic changes and tumours is impossible.

[Reconstruction of the lower urinary tract in women after cystectomy]. / Rekonstrukce dolních mocových cest u zeny po cystektomii.

BACKGROUND: The first extirpation of the urinary bladder on account of malignant papilomatosis was carried out by Karel Pawlik in 1889 as the first one in the world. At present cystectomy is indicated usually because of an infiltrating carcinoma of the urinary bladder. The objective of the present paper is, based on anatomical investigations, elaboration of a surgical technique of creating a orthotopic neovesica following cystectomy sparing a functional female urethra. METHODS AND RESULTS: In 1993-1998 32 women were operated within the age bracket of 32-72 years with a confirmed infiltration carcinoma of the urinary bladder. The authors describe in detail their own surgical technique. Day continence was achieved in 20 patients. Twelve patients suffer from stress incontinence. Eight patients have a post-micturition residue of 250-300 ml calling for a combination of medicamentous treatment and autocatheterization. The capacity of the neovesicle is the cause of nycturia: 21 patients must micturate once or twice during the night. Urodynamic studies did not reveal significant differences between patients with chronic post-miction residues and without residues. Also the mean functional length of the urethra was in both groups similar (27 mm in patients with a residue and 26.2 mm in patients without a residue). CONCLUSIONS: The elaborated surgical technique of cystectomy and creation of a neovesica makes a good quality of the patients' life possible.

[Injuries of the ureter treated at the General Medical School Hospital in Prague during the last 5 years]. / Poranení mocovodu osetrená ve Vseobecné fakultní nemocnici v Praze za posledních 5 let.

Injury of the ureter is the most frequent trauma in urological practice. The most important deal concerning a patient's expectancy is early diagnosis and adequate treatment. During 1994-1998 the authors have treated 65 patients with diagnosis an injury of the ureter. The most frequent cause was the iatrogenic injury. Timing of surgery was 5-6 weeks. A percutaneous nephrostomy was the most frequent method of initial treatment (38 patients). Ureterorhaphy (32 patients), ureterocystoneostomy (12 patients) and Boari's flap operation (5 patients) was the most frequent definitive method of the treatment.

[Sex change surgery in transsexuals]. / Operace ke zmene pohlaví transsexuálu.

Surgical conversion of sex in transsexuals implies basically removal of the testes or uterus and creation of the opposite genital. At the Urological Clinic of the General Faculty Hospital and First Medical Faculty, Charles University in Prague during the period from 1992-1998 18 male and 29 female transsexuals were operated. In male transsexualism 17 times the technique of inversion of penile skin was used and in one instance sigmoideoplasty. In female transsexualism 17 metaidoioplasties were made, three plastic operations of the neophallus from inguinal skin flaps and 25 reducing mammaplasties.

[Iatrogenic lesions of the ureter in women]. / Iatrogenní léze mocovodu u zen.

The changing etiology of ureteral lesions is associated with the expanding spectrum of ureteroscopic, gynaecological, coloproctological and vascular operations. During 1989-1995 the authors treated 60 women with a ureteral lesion, mostly in conjunction with gynaecological operations (37 patients). The assessment of the diagnosis was sometimes delayed. The most frequent initial treatment was the establishment of percutaneous puncture nephrostomy (in 47 instances before delayed reconstruction). The authors discuss the time interval between the development of the ureteral lesion and its reconstruction. The most frequent treatment was ureterorhaphy, ureterocystoneoanastomosis or Boari's flap.

[Vesicovaginal and urethrovaginal fistulae]. / Vezikovaginální a uretrovaginální pístele.

The authors discuss treatment of vesicovaginal fistulae (VVF) in 36 patients and in six patients urethrovaginal fistulae treated in 1989-1995. The most frequent cause of VVF were iatrogenic lesions after hysterectomy. Occlusion of the fistula was performed 12x by the transvesical approach, nine times by a combined transperitoneal and vaginal approach, four times by a transvesical and transperitoneal approach, eight times by the vaginal route only and three times the authors had to make a continent derivation of urine of the sigma-rectum "pouch" type. Continence by primary operation was achieved in 86%, in urethrovaginal fistulae one reoperation was necessary. With the development of radical operations in the lesser pelvis in women the incidence of iatrogenic lesions is rising slightly, however when the technique of minimal invasive reconstruction urology is used, the prognosis of occlusion of fistulae is favourable.

Female urethra-sparing cystectomy and orthotopic bladder replacement.

OBJECTIVE: Orthotopic bladder replacement after cystoprostatectomy has long become the method of choice in the treatment of infiltrating bladder cancer in males. Very good quality of life in patients thus treated stimulated the work on a similar approach applicable to females. METHODS: Twelve females were treated by urethra-sparing cystectomy. The surgical technique preserves not just the urethra itself but also the pelvic floor and relevant innervation. RESULTS: Diurnal continence was achieved in 11 patients, 1 of whom had a so-called hypercontinence with a residual volume of 300 ml. The remaining patient suffered from stress incontinence. CONCLUSION: The described urethra-sparing radical cystectomy in female patients with a urothelial tumor, with normal pelvic floor and with a low risk of secondary affection of the urethra, permits reconstructing a continent orthotopic neobladder from a detubularized intestinal segment.

[Profile of radical retropubic prostatectomy during a 5-year period]. / Profil radikální retropubické prostatektomie v petiletém období.

The authors evaluated 165 radical retropubic prostatectomies, which have been performed at the Department of Urology of the 1st School of Medicine, the Charles University and the General Faculty Hospital in Prague, from January 1992 until half of April 1997. After more precise indication criteria have been implemented, even more per cent of patients are operated in clinical T1c stage (only in this year it was up to 45%). Out of all, in 56 patients PSA exceeded 20 ng/ml, in 46 patients, there was proved seminal vesicles invasion and in 29 patients, there have been disclosed regional lymph node involvement. The postoperative decline of PSA below the 4.0 ng/ml within three months was recorded in 80% of patients with seminal vesicles involvement, but only in 69.2% of patients with nodal invasion. It may indicate the worse prognosis of latter patients. Nowadays we perform the routine peroperative staging lymphadenectomy provided PSA exceeds 10 ng/ml preoperatively and in case of presence of cancerous cells in regional lymph nodes, we do not proceed in the operation and the patient is indicated to another therapeutical modality.