[How do residents in urology evaluate their daily routine at work-a survey analysis]. / Wie wird der Berufsalltag von Weiterbildungsassistenten in der Urologie in Deutschland bewertet ­ eine Fragebogenanalyse.

BACKGROUND: The changing conditions in German hospitals is causing a shortage of young people. In order to identify starting point for improvements, the Bavarian association of urologists in collaboration with the German Society of Residents in Urology (GeSRU) conducted an online survey among residents in urology in summer of 2017. MATERIALS AND METHODS: A standardised survey composed of 38 questions was distributed to participants through a mailing list of the GeSRU. Most questions were closed-ended; however, some did allow participants to respond by means of an open-ended answer. RESULTS: A total of 218 participants provided a total of 11,764 responses: 58% were female and 42% were male. Over 70% were aged between 31 and 35 years. In all, 29% of participants responded negatively to the question asking whether they feel like their medical studies at university prepared them well for the daily routine in their workplace. Participants particularly demanded a higher degree of practical experience during their studies, as well as more teaching of soft skills. In relation to choosing their specialisation, participants considered the intern year and their clinical traineeships as crucial factors. Participants did express appreciation of their field of specialization in relation to the broad range of available treatments, the opportunity of further specialising, the clientele of patients, the opportunity of working in a small team, innovations, and the high possibilities of opening their own medical practice. On a personal level, participants specifically wished for a more structured plan relating to their further internship, involving regular meetings. They also expressed the wish for more personalised career plans, more flexible work hours, and improved advanced training, both internally and externally. CONCLUSIONS: With the aim of making urology even more attractive, participants' wishes and suggestions should be taken into consideration. These, in general, involve a more structured training plan, better working conditions with part-time programmes, and improved surrounding conditions at the workplace, in particular for families.

[Non-muscle-invasive bladder cancer: Information transfer from the clinic to the doctor's office : Results of a questionnaire study and presentation of a software solution]. / Nicht muskelinvasives Harnblasenkarzinom: Risikostratifizierung und Befundweitergabe : Ergebnisse einer Fragebogenstudie und Vorstellung einer Softwarelösung.

BACKGROUND AND OBJECTIVES: The adjuvant treatment of non-muscle-invasive bladder cancer (NMIBC) is based on the individual risk profile (RP) and its sufficient transfer from the clinic to the doctor's office. The objectives of our study were to verify the importance and degree of transfer of RP and recommendation for risk-adapted adjuvant treatment (RAAT) in patients with NMIBC as well as to develop appropriate tools for this purpose, if necessary. MATERIALS AND METHODS: An email-based survey distributed to urologists in Brandenburg, Berlin, Bavaria and Lower Saxony explored the questions mentioned above. In addition, a tool for risk stratification and information transfer for patients with NMIBC was developed and validated. RESULTS: From a total of 134 questionnaires analyzed, 55 were from clinic urologists (CUs) and 79 were from ambulant urologists (AUs). Although 9 out of 10 urologists considered the RP of importance, only 29 % of CUs and 24 % of AUs (p = 0.553) confirmed that the RP was always mentioned in medical reports. The recommendation for RAAT was confirmed from 62 % of CUs and 20 % of AUs (p < 0.001). A recommendation for RAAT in the medical report was requested by 86 % of AUs. The risk calculator presented here - to our knowledge the first with integration of the 2004 WHO grading - is delivered in all mathematically possible constellations a RP, according to guideline recommendations. CONCLUSION: Urologists in the clinic and doctor's office both attach considerable importance to the determination and transfer of RP and the recommendation for RAAT. There was evidence to suggest an overestimation of the quality of medical reports by the CU. The risk calculator provides an easy and cost-neutral option to improve risk stratification and information transfer from the clinic to the doctor's office.

[Pelvic lymph node dissection. Complication management]. / Pelvine Lymphadenektomie. Komplikationsmanagement.

Extended pelvic lymph node dissection allows exact lymph node staging and has the potential to improve prognosis. In addition to these advantages, there are some perioperative and postoperative complications. In case of transection of the obturator nerve, a microsurgical end-to-end anastomosis should be performed. The most frequent postoperative complication is (symptomatic) lymphocele which is predominantly diagnosed after extraperitoneal surgery. Meticulous lymph node dissection with clipping of lymphatic vessels, sparing the lateral wall of the external iliac artery from dissection, sufficient postoperative drainage, and application of low molecular weight heparin in the upper arm may reduce their incidence. Instillation of sclerosing agents and sufficient drainage are normally successful. If not, laparoscopic fenestration of lymphocele should be performed. Regular ultrasound examinations are necessary to diagnose and treat postoperative lymphocele in a timely manner.

[Prostate and bladder cancer: detection of disseminated tumor cells in bone marrow]. / Prostata- und Harnblasenkarzinom: Detektion von disseminierten Tumorzellen im Knochenmark.

The prognosis of prostate and bladder cancer patients is predominantly determined by the detection of distant sites of metastasis. In clinical routine, virtually only lymph node staging is of relevance to determine metastasis. Detection and characterization of disseminated tumor cells in peripheral blood or bone marrow is an additional parameter of prognostic significance. In this article, we will summarize recent progress on the prognostic value of disseminated tumor cells in bone marrow and its translation into routine clinical analysis.

[Complications of pelvic lymphadenectomy in clinically localised prostate cancer: different techniques in comparison and dependency on the number of removed lymph nodes]. / Komplikationsrate der Pelvinen Lymphadenektomie Beim Klinisch Lokalisierten Prostatakarzinom: Unterschiedliche Techniken im Vergleich und Abhängigkeit von der Anzahl Entfernter Lymphknoten.

PURPOSE: The EAU guidelines recommend extended pelvic lymphadenectomy (ePLND) or sentinel-guided PLND (SLNE) for lymph node (LN) stag-ing in prostate cancer. However, the additional expenditure and increased morbidity of ePLND has led to a limitation of the PLND area and so to a reduced detection of metastases in many clinics. The SLNE offers the advantage of selective removal of sentinel LN. Therefore, we have compared the complications of SLNE and other different PLND techniques. MATERIALS AND METHODS: Patients with prostate cancer who had received an open PLND (PLND: n = 90, PLND + radical retropubic prostatectomy: n = 409) were assessed. The complications of three PLND techniques were compared: group 1 (n = 216): SLNE, group 2 (n = 117): SLNE + modified (m) PLND (fossa obturatoria- und Iliaca-externa-region), group 3 (n = 163): SLNE + ePLND (fossa obturatoria- + Iliaca-externa- + Iliaca-interna-region). The complications were evaluated with special reference to the PLND-induced morbidity (e. g., lymphoceles). RESULTS: In SLNE the total complications were low-er than in the two more extended PLND variants. The lymphatic complications (11.2 %) were significant (χ (2) = 8.616, p = 0.013) lower than in SLNE + mPLND (21.2 %) and SLNE + ePLND (22.0 %). With an increasing number of dissected LN the complication rate increased significantly. If ≥ 15 LN have been removed total and lymphatic complications increased significantly (χ (2) = 11.578, p = 0.021; χ (2) = 12.271, p = 0.015). CONCLUSIONS: In PLND the lymphatic complications increase significantly with the number of dissected LN. The SLNE has, in spite of the dissection of LN in difficultly accessible regions (presacral, iliaca-interna-region), a low complication rate. As a method with a small number of LN to be removed, the SLNE offers a good compromise between high sensitivity and low morbidity and is therefore preferable to the more extended PLND variants.

Validation of sentinel lymph node dissection in prostate cancer: experience in more than 2,000 patients.

PURPOSE: Sentinel lymph node dissection (SLND) has replaced extended lymphadenectomy for nodal staging in several solid tumours. We present our results of SLND in prostate cancer in regard to detection and false-negative rate. METHODS: In a 2-day protocol about 300 MBq (99m)Tc-nanocolloid are injected into the prostate. Two hours later static scans of the pelvis are performed to get information about the number and location of radioactive lymph nodes. During surgery the radioactive nodes are excised with the help of a gamma probe and sent separately to the pathologist. The histological procedure includes haematoxylin and eosin staining, serial sections and immunohistochemistry. RESULTS: Since 1999, a total of 2,020 men underwent SLND alone or in combination with either standard or extended lymphadenectomy after radical retropubic prostatectomy. Lymph nodes positive for metastases were found in 16.7% of patients. The scintigraphic detection rate was 97.6% and the intraoperative detection rate 98%. For 187 lymph node-positive men who had either standard or extended lymphadenectomy in addition to SLND the false-negative rate could be calculated, resulting in false-negative findings in 11 of 187 patients (6%). CONCLUSION: Our results demonstrate that SLND in prostate cancer is a reliable procedure for nodal staging.

[Sentinel node dissection in prostate cancer: current status]. / Sentinel-Lymphadenektomie beim Prostatakarzinom - Aktueller Stand.

Sentinel lymph node (SLN) dissection is an excellent staging procedure with high sensitivity (>95%) for detecting positive nodes. When the sentinel node is negative, there is high certainty that other lymph nodes are also negative. Limitations of this technique include the use of hormone therapy over several months and a preceding transurethral resection or suprapubic adenomectomy. When sentinel node dissection is performed in patients with intermediate and high-risk prostate cancer, it should be kept in mind that when the SLN is positive, other lymph nodes can be positive, too. The positive non-SLN can be located outside the SLN region. Therefore, both sentinel and extended lymph node dissection should be used in men with a higher risk of lymph node metastases.

[Sentinel lymph node dissection in prostate cancer. Experience after more than 800 interventions]. / Sentinel-Lymphadenektomie beim Prostatakarzinom. Erfahrungen nach über 800 Eingriffen.

There is no consensus on which prostate cancer patients should undergo lymph node removal and which lymph nodes should be included. Therefore, most clinicians rely on nomograms and dispense with lymph node dissection in patients with low-risk disease. Meanwhile, there are some studies which prove that there are also lymph node metastases in patients with low-risk prostate cancer and that lymph node metastases are predominantly localized outside the region of standard lymphadenectomy. In more than 800 men we could show that lymph node metastases were found more often than shown in the Partin tables. These lymph node metastases were detected by sentinel lymph node dissection outside the region of standard and extended lymphadenectomy. Because of insufficient preoperative diagnostics it is unclear which patients have positive lymph nodes. Therefore, it is useful to perform lymph node dissection in every patient. Men with positive nodes could have a better prognosis, when sentinel and extended lymph node dissection are performed.

[Pain therapy of urologic tumors -- prophylaxis and therapy of side effects]. / Schmerztherapie bei urologischen Tumoren -- Prophylaxe und Therapie der Nebenwirkungen.

Pain is a cardinal symptom in 70 % of cancer patients. Even in developed countries, 30 to 80 % of these patients are inadequately treated. The main cause for this lack of care is not pain refractory to treatment but inadequate or incorrect use of analgesic drugs. A sufficient treatment of pain requires knowledge of the pathomechanism of pain and of the basics of pain management in cancer patients. The choice of analgesic drugs follows the WHO-recommended increase based on need. As long as possible, analgesic drugs should be given orally following a strict schedule and pre-emptively prior to renewed pain. The non-opioids are a heterogeneous group of drugs with different actions and side effects. Maximum doses exist for this group and weak opioids. A change to strong opioids is indicated when weak opioids fail to achieve sufficient pain control despite titration to the maximum dose. No upper limit exists for strong opioids and their use is limited by the side effects. The most frequent side effects are initial emesis and vomiting as well as long-lasting constipation. For this reason, most patients should be prescribed a temporary antiemetic and a laxative on a permanent basis.

[Renal neurilemoma--a rare differential diagnosis of renal tumors]. / Das Schwannom der Niere - Eine seltene Differenzialdiagnose renaler Raumforderungen.

Neurilemomas originate from the Schwann cells of nerve sheaths. They can occur ubiquitously as benign or malign variants. Renal neurilemomas are extremely rare. Imaging does not allow a certain diagnosis. Complete tumor resectioning is the only curative therapy. Effective conservative treatment is not known. Histological criteria of renal neurilemoma are: mesenchymal, spindle cell, capsulated tumor intensely positive to S-100 antiserum. Epithelial markers do not react.

[Value of sentinel node biopsy for urological tumors]. / Wertigkeit der Sentinel-Lymphknotenbiopsie bei urologischen Tumoren.

Gamma probe-guided lymphadenectomy of prostate cancer that is presumed to be localized furnishes evidence that lymphogenous spread of the disease is present considerably more often and earlier than previously assumed, even when the clinical stage is considered localized. Multiinstitutional trials have confirmed that in principle sentinel lymphadenectomy on its own is able to detect lymph node positive patients with minimal complications and a sufficient degree of certainty. Sentinel lymphadenectomy for penile cancer is an undemanding surgical procedure and in contrast to inguinal lymphadenectomy can be considered minimally invasive. Decisions on indication and necessity for an additional inguinal lymphadenectomy depending on tumor stage and local findings in the inguinal lymph nodes are handled quite differently in various centers and should be further standardized. The most recent studies on sentinel lymphadenectomy for urinary bladder and testicular cancer demonstrate that on principle the procedure is likely feasible also for these tumor entities. Whether it is possible to replace standard treatment methods with these procedures or at least have them serve an ancillary function remains to be determined in further investigations. Basically, the premise holds true that for all urological tumor entities before standard diagnostic techniques are abandoned, the value of exclusively performing sentinel lymphadenectomy must be adequately validated. It does not suffice to rely on the results from other working groups. It is in fact essential that the accuracy of the method - the feasibility of which can be influenced by numerous factors - be assessed by comparison with a standard lymphadenectomy performed in one's own center.

[Unenhanced spiral computerized tomography in acute diagnosis of flank pain. Examination in contraindications for contrast medium administration]. / Native Spiral-Computertomographie in der Akutdiagnostik von Flankenschmerzen. Untersuchung bei Kontraindikationen zur Kontrastmittelgabe.

The diagnostic value of unenhanced helical computed tomography was investigated in a prospective study. In 53 patients (aged 35 to 82 years) with acute flank pain tomography was performed in addition to abdominal plain film and ultrasound examination. All 53 patients had a contraindication for intravenous administration of contrast medium. Ureteral calculi were either confirmed or excluded by retrograde ureteropyelography in 44 cases, in 9 patients by asservation of calculi and clinical follow-up. Helical computed tomography was able to precisely identify all of the 34 ureteral calculi, whereas abdominal plain films led to 6 false positive and 17 false negative findings. In 1 patient with retroperitoneal lymphoma (diagnosed by CT) false positive findings occurred. Unenhanced helical computed tomography reaches a distinctively increased diagnostic value (sensitivity 100%, specificity 95%, accuracy 97%) in the evaluation of acute flank pain as compared to conventional radiologic imaging and ultrasound. This non-invasive procedure is to be considered method of choice for patients with contraindications for the application of radiopaque material.

Radioisotope guided pelvic lymph node dissection for prostate cancer.

PURPOSE: The localization of lymph node metastases in prostate cancer varies enormously. Due to high morbidity complete pelvic lymphadenectomy is often decreased to modified staging lymphadenectomy, resulting in loss of sensitivity for detecting micrometastases. Based on the promising results of intraoperative gamma probe application for identifying sentinel lymph nodes in malignant melanoma, breast and penis cancer, we identified sentinel lymph nodes in prostate cancer using a comparable technique. MATERIALS AND METHODS: In 117 patients 99mtechnetium nanocolloid was transrectally injected directly into the prostate under ultrasound guidance 1 day before pelvic lymphadenectomy. Thereafter dynamic lymphoscintigraphy was done. Initially lymph nodes identified as sentinel lymph nodes by the gamma probe were removed and subsequently modified pelvic lymphadenectomy was performed. RESULTS: Lymphatic metastasis was detected in 28 cases. An average of 4 sentinel lymph nodes were identified per patient in 25 of 27 patients with micrometastasis, of which those in 24 contained micrometastasis for 96% sensitivity. In contrast, sensitivity of modified pelvic lymphadenectomy was 81.5%. In 16 patients only sentinel lymph nodes were positive. An average of 21.8 lymph nodes (range 10 to 51) was dissected per patient at pelvic lymphadenectomy. Lymph node metastasis was noted in 6 of the 46 patients with a prostate specific antigen between 4 and 10 ng./ml. and in 8 of the 64 with a stage pT2 tumor. CONCLUSIONS: Our study shows individual variability of lymphatic drainage of the prostate and limited sensitivity for detecting positive lymph nodes when the pelvic dissection area is limited. Furthermore, our experience implies that the identification of sentinel lymph nodes is feasible, not only in breast cancer and malignant melanoma, but also in prostate cancer using a comparable technique.

Disseminated cytokeratin positive tumor cells in the bone marrow of patients with prostate cancer: detection and prognostic value.

PURPOSE: Previous investigations have shown that cytokeratin 18 positive bone marrow cells in localized and lymphatically spread prostate cancer correlates with neither established prognostic factors nor with the biochemical and clinical course after radical prostatectomy. Since the well-known down-regulation of cytokeratin 18 in tumor cells may lead to false-negative results, we asked whether staining with a pan-cytokeratin antibody recognizing a common epitope of cytokeratins 8, 18 and 19 would result in different data. MATERIALS AND METHODS: Preoperative bone marrow aspirates of 82 patients with localized (N0) and lymphatically spread (N1) prostate cancer were examined using the monoclonal antibody cytokeratin 2 and the pan-cytokeratin antibody A 45-B/B3, called A 45. RESULTS: In contrast to findings with the cytokeratin 18 antibody, those with the pan-cytokeratin antibody correlated with the biochemical course. At a median followup of 1,477 days (4 years) patients with pan-cytokeratin positive cells in the preoperative bone marrow aspirate had biochemical progression significantly earlier than those with pan-cytokeratin negative results (mean time to prostate specific antigen relapse 886 versus 1,409 days, p < or =0.004). Compared with other parameters, such as prostate specific antigen, pathological stage and Gleason score, preoperative pan-cytokeratin findings proved to be an independent prognostic factor. CONCLUSIONS: Cytokeratin positive cells in the bone marrow also have prognostic relevance in prostate cancer. The comprehensive analysis of these cells, studies of the individual course of these findings and sufficiently long followup allow us to discuss whether and under what conditions metastasis may develop from 1 or several cytokeratin positive cells.

Biochemical course after radical retropubic prostatectomy: preliminary results.

OBJECTIVE: To investigate prognostic factors in localized and lymphatically spread prostate cancer. METHODS: The biochemical course after radical retropubic prostatectomy in 306 patients was subject to a retrospective analysis. RESULTS: Prostate-specific antigen (PSA), Gleason score (prostatectomy specimen) and pathological stage proved to be prognostically relevant (p < 0.0001). PSA, Gleason score and tumor stage also were to be considered as (independent) prognostic factors by means of a multivariate analysis (p < 0.001), whereas perineural invasion (prostatectomy specimen) and preoperative bone marrow findings (CK 2) had no impact on the course of the disease. After a median follow-up of 1,307 days (3.6 years), a biochemical relapse occurred in 41.8%. CONCLUSION: High preoperative PSA values and the resulting high portion of advanced tumor stages are a possible basis for the high biochemical relapse rate in our collective. The learning curves of several surgeons and the previously more restrictive pelvic lymphadenectomy (surgical understaging) may also be considered causes.

Unenhanced helical computed tomography in the evaluation of acute flank pain.

OBJECTIVE: The diagnostic value of unenhanced helical computed tomography (CT) for the evaluation of acute flank pain is investigated in a prospective study. PATIENTS AND METHODS: In 125 patients aged 18-86 years, we performed unenhanced helical CT in addition to abdominal plain film, abdominal ultrasound and urinalysis as a diagnostic measure for acute flank pain. Ureteral calculi were confirmed or, respectively, excluded by retrograde ureteropyelography in 80 cases. In the other cases, diagnosis was verified by clinical course and/or stone asservation. RESULTS: In 91 of 125 patients the flank pain was caused by a ureteral calculus. In 67 of 91 patients with urolithiasis, stones could be collected for analysis. Helical CT was able to precisely identify 90 ureteral calculi. Abdominal plain films led to 8 false-positive and 48 false-negative findings. Thus, sensitivity of plain radiography, ultrasound and urinalysis was 47, 11 and 84% with a specificity 76, 97 and 32%, respectively. CONCLUSIONS: Unenhanced helical CT reaches a distinctively increased diagnostic value (sensitivity 99%, specificity 97%) in the evaluation of acute flank pain as compared to plain radiography, ultrasound and urinalysis.

First experience with gamma probe guided sentinel lymph node surgery in penile cancer.

Because of the curative approach, the detection of lymph node metastases in squamous cell carcinoma (SCC) of the penis is of significant clinical relevance. Sentinel lymph node (SLN) identification by means of lymphangiography has been proven to be insufficiently safe. However, the high morbidity of inguinal lymphadenectomy and the considerable individual variability regarding the location of lymph node metastases justify the necessity of a technique that enables the identification of SLNs. Since 1998, SLNs have been intraoperatively identified and selectively dissected, after peritumoral injection of technetium-99m nanocolloid and using lymphoscintigraphy, in three patients (one with malignant melanoma and two with SCC). At least one SLN could be detected in each patient. The maximum surgical time was 30 min. There were no severe complications. Lymph node metastases did not occur in any patient. Upon a mean follow-up of 10 months, all patients are currently free of tumor. Owing to the long-term results of sentinel lymphadenectomy in malignant melanoma of other locations and our preliminary results with respect to penile carcinoma. we consider the current method appropriate as the only primary operation for lymph node staging in early stages and, in combination with modified inguinal lymphadenectomy, in locally advanced stages.

The sentinel lymph node concept in prostate cancer - first results of gamma probe-guided sentinel lymph node identification.

OBJECTIVE: The goal of this study was to show lymphatic drainage and to verify the validity of lymphoscintigraphy for the identification of the sentinel lymph node (SLN) in prostate cancer. Furthermore, the question is to be raised whether the standardized pelvic lymphadenectomy is a sufficient means for also detecting solitary micrometastases. PATIENTS AND METHODS: Eleven patients with prostate cancer received a sonographically controlled, transrectal administration of a technetium-99m colloid injected directly into the prostate 1 day prior to pelvic lymphadenectomy. 20 min later the dynamic lymphoscintigraphy was carried out. During surgery, the SLNs were identified by using a gamma probe. The standard pelvic lymphadenectomy was performed after removal of the SLN. RESULTS: In 3 of 4 patients with micrometastasis the spread of the tumor could exclusively be found in those nodes which had been identified as SLNs by means of scintigraphy by combining preoperative lymphoscintigraphy and intraoperative gamma probe detection. In 2 cases, the pathologically proved SLNs were situated at the anteromedial region of the internal iliac artery, thus being located outside of the standard pelvic lymphadenectomy area. In 1 patient, however, the micrometastasis was found beyond those nodes which had been identified as SLN intraoperatively. CONCLUSIONS: In the future, we expect the restriction of pelvic staging lymphadenectomy to scintigraphically proved SLN. The perioperative morbidity may be reduced by increasing the sensitivity of the detection of micrometastases. Our data confirm earlier perceptions, according to which even modified standardized pelvic lymphadenectomy is considered insufficient in terms of the detection of micrometastases.

Micrometastases of bone marrow in localized prostate cancer: correlation with established risk factors.

PURPOSE: The presence of cytokeratin 18-positive cells in bone marrow correlates with conventional risk factors in many tumors. We examined whether this was also valid for localized or lymphatically spread prostate cancer. PATIENTS AND METHODS: Immediately before radical prostatectomy, bone marrow aspirates from both sides of the iliac crest were taken from 287 patients. The presence of cells containing cytokeratin 18 was interpreted as micrometastasis. RESULTS: In patients with negative lymph nodes (n = 219), conventional risk factors (Gleason score, pathologic stage, ploidy, and preoperative prostate-specific antigen) did not correlate with the preoperative detection of cells containing cytokeratin 18. There was also no correlation with lymph node metastases. Furthermore, there was no interdependency between the preoperatively detected number of cells and the established risk factors. CONCLUSION: We assume the presence of epithelial cells in bone marrow to be an independent parameter, the clinical importance of which must be substantiated by further studies.