[Complications and their management after urinary diversion]. / Komplikationen und deren Management nach Harnableitung.

BACKGROUND: Bladder cancer is a common disease. It is predicted that 11,900 men and 4,500 women in Germany will be diagnosed with invasive bladder cancer in 2014. The cystectomy, which is standard treatment in muscle-invasive bladder cancer, requires urinary diversion. PURPOSE: The goal of this article is to present the complications associated with urinary diversions and their management. METHODS: Based on a selective literature search in PubMed and our own clinical experience, the options for urinary diversion and their management are discussed. RESULTS: In patients treated with curative intent, orthotopic bladder replacement is preferred. In patients with palliative intent, incontinent cutaneous urinary diversion is commonly used. The present work shows the variety of early and late complications, peri-/postoperative mortality, and the management of these patients. CONCLUSION: After cystectomy, various methods for urinary diversion are available, which can be used in curative and/or palliative intent. Crucial to the success and the long-term satisfaction of the patients is selection of the right urinary diversion method.

Combination of C-TRUS with multiparametric MRI: potential for improving detection of prostate cancer.

PURPOSE: To improve the detection of prostate cancer, especially in pre-biopsied patients, a guided biopsy based on radiologic findings is an option. We addressed the question, whether the combination of multiparametric MRI and computerized transrectal ultrasound (C-TRUS) improves the detection of prostate cancer. METHODS: Twenty patients suspicious of having prostate cancer were included. Seventeen patients were pre-biopsied once or more. Each patient was examined by multiparametric MRI and C-TRUS, followed by a guided transrectal prostate biopsy series. Patients were stratified in a "low-risk" and "high-risk" group. The results were analyzed using descriptive statistics. RESULTS: In 58 % (11 pat.) of patients, prostate cancer was found. In the "high-risk" group, biopsy in 73 % (8 pat.) of patients was positive for prostate cancer. All prostate cancer patients were found by C-TRUS-guided biopsies, whereas MRI did not reveal cancer in 27 %. 72 % (8 pat.) of patients had undergone radical prostatectomy. 65 % (6 pat.) had higher tumor stages after prostatectomy and 62.5 % (5 pat.) had higher Gleason-score. CONCLUSIONS: Combination of multiparametric MRI and C-TRUS seems to improve detection of prostate cancer, especially in high-risk patients. Detection rates of C-TRUS in this study could confirm those of the primary C-TRUS studies. The benefit of MRI is the additional visualization of the tumor extension. The technique is an option for pre-biopsied patients. Both imaging methods often fail to predict correct tumor stage, but further studies are necessary.

Comparison of transrectal prostate biopsy results with histology of transurethral resection of the prostate in men undergoing high-intensity focused ultrasound.

INTRODUCTION: The aim of our study was to evaluate the significance of transurethral resection of the prostate (TURP) to detect prostate cancer (PCa). A comparison was performed of the TURP specimens of patients undergoing high-intensity focused ultrasound (HIFU) with the core biopsies. MATERIALS AND METHODS: TURP before undergoing HIFU therapy was performed in 106 patients without neoadjuvant treatment. The resected tissue was subjected to histopathological evaluation and compared to the histological results of transrectal prostate biopsy. RESULTS: Cancer was detected in the resected tissue of 69 patients (65%). A positive correlation of the amount of resected tissue and detection of PCa could be demonstrated in a multivariate analysis. CONCLUSIONS: With a rate of 65% PCa detected by TURP, our data provide evidence that TURP might be suitable to detect PCa in a small group of selected patients with continuously rising PSA levels and several negative biopsies. On the other hand, these data underline/reinforce the necessity to treat the whole gland using modern treatment modalities such as HIFU and cryotherapy.

Utility of immunohistochemistry markers in the interpretation of post-high-intensive focussed ultrasound prostate biopsy cores.

PURPOSE: To overcome the difficulties in the interpretation of postoperative tumor obtaining biopsy cores for patients who treated their prostate cancer with high-intensity focussed ultrasound (HIFU) therapy. METHODS: The H&E slides of 58 patients with residual prostate cancer after HIFU treatment were systematically reviewed. Correlation between the pathologist's findings and immunohistochemical expression of MIB-1, alpha-Methyl-Co-Racemase and 34ßE-12 staining was analyzed. RESULTS: Mean time from treatment to biopsy was 40.2 (8-208) weeks. The expert review of the H&E slides identified 40 patients with viable carcinoma in the post-HIFU biopsy cores. 18 patients were revised to necrosis-only-tumors. These biopsies were performed not later than 16 weeks after HIFU treatment (median 10.9 weeks, range 8-14). Both MIB-1 and AMACR staining displayed significant differential expression in viable carcinoma (p < 0.001) compared to necrosis tumors. Referring to viable carcinoma tissue, AMACR staining index was significantly rising, the longer treatment dated back from biopsy (p < 0.002). In this context, 34-ß-E12 stained negative through all tumor areas and positive in the majority (85%) of the surrounding non-neoplastic epithelium. CONCLUSIONS: AMACR and MIB-1 reliably differentiate viable carcinoma from a process of ongoing irreversible necrosis in early post-HIFU prostate biopsy cores and therefore proposed-in addition with 34 beta-E12-as useful markers exposing suspicious tumor foci in difficult cases.

[Guidelines: reality and quality]. / Leitlinien: Realität und Qualität.

The aim of guidelines is to increase the quality of care in clinical practice. Any influence or financial support by the pharmaceutical industry must be excluded. In urology only two S3 guidelines have been published in German and all others are more or less recommendations (S1). The example of the second opinion project on testicular germ cell tumors shows that a reduction of recurrence, morbidity and mortality can be achieved by the consistent application of guidelines. Oncological guidelines are often focused on the unidirectional parameter overall survival but do not include other important aspects, such as long-term morbidity or quality of life.

Pioglitazone, etoricoxib, interferon-α, and metronomic capecitabine for metastatic renal cell carcinoma: final results of a prospective phase II trial.

We enrolled 45 patients with metastatic renal cell carcinoma (RCC) at a progressive disease between March 2003 and April 2008 to assess the impact of an anti-inflammatory treatment regime in combination with metronomic low-dose chemotherapy. 42% of the patients had been systemically pre-treated. Therapy consisted of etoricoxib 60 mg daily plus pioglitazone 60 mg daily, day 1+, low-dose interferon-α 4.5 MU sc three times a week, week 1+ and low-dose capecitabine 1 g/m(2) twice daily orally for 14 days, every 3 weeks, day 1+, until disease progression. Objective response was observed in 35% of the patients (PR 27, CR 9%), which was paralleled by strong CRP decline for all patients with initially elevated CRP levels (n = 32). CRP values decreased from mean 42.3 mg/L (range 9.1-236), to 11.1 mg/L, (range 1.1-35.6), P = 0.006. Median overall survival and progression-free survival for the total cohort were 26.9 and 7.2 months for patients with elevated CRP 24.4 and 11.3 months (95% CI, 22.8-31.0/5.7-16.9) and 13.8-2.6 months (95% CI, 6.5-21.1/0.4-4.8) for the non-elevated CRP group, respectively (P = 0.082/0.017). Median observation time: 26.1 months; Overall survival at 5 years: 18%. Toxicity>WHO grade 3 was reported: Hand-foot syndrome in 16 patients (36%), diarrhea in 4, and pneumonia in 2 patients. Our data allow us to conclude that the control of tumor-associated inflammation is an important therapeutic principle in patients with metastatic RCC.

[Hydronephrosis: urgency of interventions and recommended times for surgical correction]. / Harntransportstörungen (Hydronephrosen): Dringlichkeiten der Interventionen und empfohlene Zeitpunkte der Korrekturen.

The prevalence of malformations of the kidneys is quite high compared to other congenital malformations. In a study of the Association for Neonatology of Mecklenburg-West Pomerania examining 37,634 births, a hydronephrotic kidney was diagnosed in 16.7 of 10,000 children. Depending on the type and severity of the congenital malformation it might be difficult to find out when there is a risk for loss of renal function. Unfortunately, in 2010 health politicians (the Gemeinsame Bundesausschuss) voted against routine ultrasound screening for renal abnormalities in newborns despite an increasing number of pre- or postnatally diagnosed dilated kidneys in recent years. Will this lead to a decrease in the diagnosis of hydronephrosis with possible loss of renal function later on? According to Roth et al. the incidence of in utero dilatations of the urinary tract is about 1:100, but only 1:500 children have a clinically relevant problem. This raises the question of which of these young patients need an intervention and which might be monitored expectantly.

Modular therapy approach in metastatic castration-refractory prostate cancer.

PURPOSE: The present multi-center phase II study was designed to support the hypothesis that networking agents, which bind to ubiquitous accessible targets in metastatic castration-refractory prostate cancer (CRPC) may counteract neoplasia-specific aberrant cellular functions, thereby mediating PSA response (primary endpoint). METHOD: Patients with metastatic CRPC received low-dose chemotherapy with capecitabine 1 g twice daily plus dexamethasone 1 mg daily for 14 days every 3 weeks, COX-2 blockade with rofecoxib 25 mg (or etoricoxib 60 mg) daily combined with pioglitazone 60 mg daily until disease progression. RESULTS: Thirty-six consecutive patients with metastatic CRPC were enrolled, of whom n = 18 (50%) had been extensively pretreated with radio- or radionuclid therapy and n = 16 (44%) with chemotherapies; n = 8 patients (22%) were medically none-fit, having an ECOG-score of 0-2. Nine of 15 patients with PSA response >50% showed objective response. Median time to PSA response was 2.4 months (range 1.0-7.3 months). Two of 9 patients responding with PSA < 4 ng/ml showed complete resolution of skeletal lesions after 9 and 16 months; 13 patients had a stable course of disease, and 5 patients experienced progressive disease. Median progression-free survival (PFS) was 4.0 months (2.8-5.1 months) and median overall survival (OS) 14.4 months (10.7-17.2 months). Toxicities according to WHO grade II were noticed in 9 patients. CONCLUSIONS: This new combined modular therapy approach is able to induce major responses including resolution of skeletal lesions in patients with CRPC. Furthermore, the study may clinically support the above-mentioned hypothesis.

Acupuncture for pain in extracorporeal shockwave lithotripsy.

BACKGROUND AND PURPOSE: In most cases, analgesia is required for extracorporeal shockwave lithotripsy (SWL) treatment. Commonly, a combination of a sedative and a synthetic opioid is used, with a wide range of undesirable side effects. To provide an alternative analgesic especially for outpatients, we performed a prospective trial investigating the usefulness of acupuncture. PATIENTS AND METHODS: A series of 90 patients were included in the study, 49% of whom presented with renal calculi and 10% with proximal-, 10% with middle-, and 31% with distal-ureteral stones. Pain control was performed by acupuncture in the traditional Asian method. The intensity of pain and patient satisfaction were assessed a visual analog scale (VAS). Patients with previous SWL under conventional analgesia also were asked about differences in pain and satisfaction. RESULTS: No significant side effects occurred. The median pain score on the VAS was 2/10 (interquartile range 1). Six patients (6.6%) specified a pain intensity of >4, and in 4 patients (4.4%), a conventional analgesic had to be given to finish SWL. The median satisfaction level was 2/5 (interquartile range 1). Nearly all (93.4%) of the patients would opt again for acupuncture in case of repeated SWL. CONCLUSION: In many patients, acupuncture achieves satisfactory pain control for SWL. Further randomized multi-institutional studies are needed to confirm this conclusion.

Critical role of nitric oxide for proliferation and apoptosis of bone-marrow cells under septic conditions.

Sepsis is a state of high turnover of bone-marrow cells. Nitric oxide (NO) is reported to be involved in cell proliferation and demise. Murine bone-marrow cells were incubated with lipopolysaccharide together with tumor necrosis factor alpha, interferon gamma and interleukin-1 beta for 48 h. The basal proliferation rate of the cells remained unchanged, but granulocyte-macrophage colony stimulating factor-induced proliferation was suppressed and the percentage of apoptotic cells significantly raised. Levels of nitrite in the culture supernatants were inversely correlated with the suppression of proliferation, but directly correlated with apoptosis. The NO synthesis inhibitor N-methyl-arginine inhibited the suppression of proliferation as well as the induction of apoptosis and NO synthesis. Our results indicate that NO is a negative feedback regulator of cell turnover in sepsis, which limits growth-factor-induced proliferation and induces apoptosis of bone marrow cells.