Management of Germ Cell Tumours of the Testes in Adult Patients: German Clinical Practice Guideline, PART II - Recommendations for the Treatment of Advanced, Recurrent, and Refractory Disease and Extragonadal and Sex Cord/Stromal Tumours and for the Management of Follow-Up, Toxicity, Quality of Life, Palliative Care, and Supportive Therapy

OBJECTIVES

We developed the first German evidence- and consensus-based clinical guideline on diagnosis, treatment, and follow-up of germ cell tumours (GCT) of the testes in adult patients. We present the guideline content in 2 separate publications. The present second part summarizes therecommendations for the treatment of advanced disease stages and for the management of follow-up and late effects.

MATERIALS AND METHODS

An interdisciplinary panel of 42 experts including 1 patient representative developed the guideline content. Clinical recommendations and statements were based on scientific evidence and expert consensus. For this purpose, evidence tables for several review questions, which were based on systematic literature searches (last search in March 2018), were provided. Thirty-one experts, who were entitled to vote, rated the final clinical recommendations and statements.

RESULTS

Here we present the treatment recommendations separately for patients with metastatic seminoma and non-seminomatous GCT (stages IIA/B and IIC/III), for restaging and treatment of residual masses, and for relapsed and refractory disease stages. The recommendations also cover extragonadal and sex cord/stromal tumours, the management of follow-up and toxicity, quality-of-life aspects, palliative care, and supportive therapy.

CONCLUSION

Physicians and other medical service providers who are involved in the diagnostics, treatment, and follow-up of GCT (all stages, outpatient and inpatient care as well as rehabilitation) are the users of the present guideline. The guideline also comprises quality indicators for measuring the implementation of the guideline recommendations in routine clinical care; these data will be presented in a future publication.

Endocrine alteration in the adrenal gland in kidney transplant patients

INTRODUCTION

Endocrine alterations associated with chronic renal failure have been reviewed recently. Some of these alterations are of clinical relevance. The aim of this study was to investigate the effect of renal transplantation on the endocrine system of the adrenal gland of the transplant recipients.

METHODS

The serum angiotensin-converting enzyme (SACE), plasma renin (PR) and plasma aldosterone (PA) were examined in 30 patients before and after renal allotransplantation. Additionally measured parameters were blood pressure, serum creatinine, potassium, sodium, the duration of dialysis and immunosuppressive medication.

RESULTS

Six weeks after renal transplantation, serum creatinine decreased from 820.07 +/- 172.01 to 138.12 +/- 67.54 micromol/l. In the same period, serum potassium decreased from 5.42 +/- 0.89 to 4.17 +/- 0.42 mmol/l. PA and PR decreased from 1,150.84 +/- 976.06 to 233.52 +/- 217.07 micromol/l, and from 121.07 +/- 100.12 to 26.16 +/- 10.86 microU/ml, respectively. SACE decreased from 0.21 +/- 0.21 to 0.13 +/- 0.11 micromol/l. No significant correlation was seen with blood pressure, serum sodium, the duration of dialysis and immunosuppressive drugs. Additionally, 2 patients with acute renal graft dysfunction showed significant increases in PR and PA. After successful treatment both levels declined very quickly to prerejection levels. Patients after binephrectomy show no elevation in PR (5-47 microU/ml) or PA (21-416 micromol/l) neither before nor after renal transplantation.

CONCLUSIONS

We conclude that renal transplantation has profound effects on the recipient's renin-angiotensin-aldosterone system. Because of the rapid depression after renal transplantation, it does not appear to be involved in the pathogenesis of post transplantation hypertension but may reflect a role for repair processes after renal allotransplantation.

Renal cell carcinoma in renal graft recipients and donors: incidence and consequence

INTRODUCTION AND OBJECTIVES

Numerous studies have reported an increasing incidence of small renal cell carcinoma (RCC). De novo RCC in a renal allograft is a rare event and has special implications in renal transplant recipients. The objective of this study was to retrospectively evaluate the incidence of RCC in renal graft recipients and donors and to determine a procedure in cases with newly detected small renal tumors at the time of kidney preparation before transplantation.

MATERIAL AND METHODS

We mailed a questionnaire to 38 German transplant clinics and received answers from 27 centers. A total of 10,997 renal graft recipients were included in the period of 1990-1998.

RESULTS

In 30 kidneys (0.273%) RCC was detected at the time of preparation before transplantation. There were 23 male and 3 female donors. No bilateral RCC was described. The mean age of the donors with RCC was 50.9 years (range 37-72 years). The tumors had a mean size of 2.2 cm (range 0.4-6 cm). 67% of the patients had a renal tumor smaller than 20 mm. In 26/27 centers the decision to transplant relies on the result of the immediate section for microscopic examination. 16 patients (0.145%) developed RCC 3-12 years after renal transplantation (mean 7.4 years). The mean tumor size was 2.5 cm (range 2-2.8 cm). In 50% a grade 1 and in the other 50% a grade 2 carcinoma was found.

CONCLUSIONS

Because of the RCC incidence in donor candidates we recommend an ultrasound screening of the native kidneys before renal explantation and an immediate preparation of the kidney surface especially in donors older than 45 years. In cases with small renal lesions we recommend an immediate section for microscopic examination before transplantation to prevent tumor implantation into an otherwise healthy patient. The frequency of RCCs after renal transplantation necessitates careful clinical and instrumental examinations in organ-transplanted recipients both before and at regular intervals after transplantation, including the patient's kidneys.

A bridge between neuroscience and oncology: prostate cancer genesis. A 'negative' consequence of learning?

Prostate cancer has become the most commonly diagnosed cancer in men over recent years. The initiating mechanism for tumorigenesis within the prostate remains an unknown. The observation, that the cancer incidence in patients with chronic neurological disabilities is significantly lower than in the normal population lead to the hypothesis, that changed processing due to a barrage of aberrant sensory information within a healthy CNS can trigger events within the prostate cell, that cause malignant transformation. There is a broad overlap of cellular mechanism of gene expression, that lead to either long term potentiation, learning and memory storage or deregulated differentiation and malignant transformation.

Chronic perineal pain and lower urinary tract dysfunction--a clinical feature of the "Gulf War syndrome"?

A Persian Gulf War veteran presented to the University Neuro-Urology service for management of severe chronic perineal pain. The overall physical and neurological exam was unremarkable. However, the rectal exam and the urodynamic study revealed a severe pelvic floor dysfunction. A neuro-behavioral approach is recommended and discussed.

The male chronic pelvic pain syndrome

Suffering chronic pain is a common and debilitating problem that significantly impairs the quality of life of affected patients. Because we continue to struggle with chronic pelvic pain disorders both diagnostically and therapeutically, a neuro-behavioral perspective should be used in an attempt to explain pathways and neurophysiological mechanisms, and to improve diagnostics and treatment of male pelvic pain. First, however, malignant and acute/chronic bacterial disease has to be excluded as a cause of chronic pain in every single case. Then diagnostic approaches should screen for lower urinary tract dysfunction, pelvic floor functional disorders, and disturbed reflex integrity within the pelvic area. Treatment approaches for the male chronic pelvic pain syndrome could be divided into causal and symptomatic. Causal treatment approaches try to influence basic mechanisms generating and supporting chronic pain. In most cases a symptomatic approach is needed to relieve pain immediately. Because generally accepted treatment protocols and studies are missing, the following approach in the individual patient is recommended: (1) symptomatic treatment for immediate pain relief, (2) diagnostic work-up, (3) causal treatment trial.

Fetal fibronectin: a new screening-marker for bladder cancer?

Early detection of transitional cell carcinoma (TCC) of the urinary bladder is essential for effective treatment. While several serum markers have been evaluated, none have been widely accepted for practical clinical use. Thus, urinary markers have been introduced and investigated to detect the evidence of bladder cancer. But sensitivity and specificity range around 80% respectively. In a prospective study we evaluated fetal fibronectin in the urine of patients with TCC of the urinary bladder. The positivity of oncofetal fibronectin was measured in morning urine samples by membrane immunoassay. This FFN membrane immunoassay is a qualitative test, a solid-phase immunogold assay. A positive sample will result in a single spot after binding of the oncofetal fibronectin-immunogold complex to the membrane containing a monoclonal antibody specific to oncofetal fibronectin (FDC-6, which specifically recognizes III-CS region). The morning urine samples were collected from patients with TCC before they underwent transurethral resection (n=40, 34 non-invasive and 6 invasive carcinomas) and healthy controls (n=20). Oncofetal fibronectin was investigated in the surgical samples by immunohistochemistry (antibody FDC-6, APAAP technique). We found a positive result for oncofetal fibronectin in 38/40 patients with transitional cell carcinoma of the urinary bladder. Two patients with a small pTaG1-TCC showed negative results. In the urine of healthy controls no positive results were detected. Thus, there is a sensitivity of 95% and a specificity of 100%. The TCC was demonstrated as a source of oncfn. To our knowledge this is the first study showing that patients with an evident TCC have a demonstrable amount of oncofetal fibronectin in the urine. We conclude that a positive result is common in TCC-patients. The sensitivity and specificity of this test seems to be extraordinarily high. Because of the small number of cases further studies are required.

Sacral nerve stimulation for pain relief in interstitial cystitis

A 60-year-old woman was treated for severe interstitial cystitis pain using sacral nerve stimulation. Pain and accompanying bladder dysfunction were improved by temporary and permanent sacral nerve stimulation. Six months after implantation of a sacral neuromodulator the patient is pain free and significantly improved on bladder dysfunction. Interstitial cystitis may be an indication for functional electrostimulation.

Similarity of distributions of spinal c-Fos and plasma extravasation after acute chemical irritation of the bladder and the prostate

PURPOSE

Persistent pain in referred areas and voiding dysfunction are characteristic symptoms of chronic abacterial prostatitis. Since referred pain from visceral organs is considered a neurological event, it appeared reasonable to hypothesize that the persistent pain associated with prostatitis might also be explained by neural mechanisms. Neurogenic plasma extravasation and c-fos expression in the spinal cord, after chemical irritation of the rat prostate, was identified as a method to investigate the neurogenic aspect of prostatic inflammation.

MATERIALS AND METHODS

The distribution of plasma extravasation using Evans blue dye was determined after chemical irritation of the prostate and bladder of the rat, and the distribution of dye extravasation was analyzed. c-fos expression within the spinal cord was determined immunocytochemically after chemical irritation of the prostate, bladder and superficial somatic region determined by the dye extravasation as a referred pain area (tail root).

RESULTS

Chemical irritation of the prostate resulted in plasma extravasation in L5 to S2 dermatomes (primarily in L6 and S1). In rats receiving bladder irritation, the distribution of plasma extravasation showed a similar pattern to that observed in animals receiving prostatic irritation. Chemical irritation of the 3 structures resulted in expression of c-fos positive cells within the lumbosacral spinal cord. With each treatment the majority of c-fos positive cells were in the L6 and S1 segments. In all 3 groups the highest percentages of c-fos positive cells were observed in deeper laminae, including the dorsal commissure and sacral parasympathetic nucleus.

CONCLUSIONS

Our results strongly suggest that referred pain status in inflammation of the bladder and prostate is neurogenically mediated. Based on these studies, there should be significant overlaps of nociceptive neurons within the spinal cord, which receive nociceptive inputs from pelvic soma and viscera.

Preoperative simulation of partial nephrectomy with three-dimensional computed tomography

OBJECTIVE

To evaluate prospectively the accuracy of computer-aided three-dimensional (3D) volume-rendered computed tomography (CT) in determining the appropriate anatomical limits (tumour size, tumour location, multifocality and vascular supply) and as a potential tool in the preoperative simulation of nephron-sparing surgery (NSS) in patients with small-volume renal cell carcinoma (RCC).

PATIENTS AND METHODS

The study included 36 patients who underwent transperitoneal radical nephrectomy for RCC of < 4 cm diameter. Helical CT was undertaken before surgery and the extent of the tumour, the course of major renal arteries and veins, and the relationship of the tumour to the collecting system were shown by 3D volume-rendered CT. The CT findings were compared with the pathological results of all kidney specimens, obtained using 3-mm step-sections.

RESULTS

Before nephrectomy, 39 renal tumours were identified in the 36 patients; three renal lesions of < 4 mm were not detected. All main venous branches and 42 of 43 arteries were identified by 3D volume-rendered CT. Knowing these features, a partial nephrectomy was simulated; a surgical lesion to the pelvicalyceal or vascular system which would have been produced by the simulated surgery was displayed in colour on the simulated surface of the section.

CONCLUSION

Computer simulation provided an excellent 3D reconstruction of all kidneys, including the tumour, vasculature and renal hilum, allowing a significantly better preoperative evaluation of the renal mass. Visualizing possible resection margins and predicting the operative risks seem to be major advantages of this new method, especially when preparing for complex surgery. Reconstructed 3D CT appears to be a useful tool for defining the indications for and limitations of NSS.

How accurate is diagnostic imaging in determination of size and multifocality of renal cell carcinoma as a prerequisite for nephron-sparing surgery?

BACKGROUND

The indication for elective nephron-sparing surgery (NSS) in renal cell carcinoma (RCC) is under discussion in the urological literature. The main problem of NSS is the multifocality of RCC. The presented study was performed to asses the accuracy of pre- and intraoperative ultrasound (US), and computerized tomography (CT) in determination of tumor size and detection of multifocal lesions.

MATERIALS AND METHODS

Tumor size was measured by preoperative US and CT and compared with the tumor diameters in gross sections of the neoplastic kidneys. Multifocality was determined by 3-mm step sectioning of the nephrectomy specimen, and the results were correlated with preoperative US and CT on the one hand, and the ex situ sonography of the nephrectomized kidney on the other hand.

RESULTS

US and CT show similar results in the determination of the tumor size. In only 22.9%, preoperative US and CT were able to detect multifocal tumors. Ex situ sonography had a sensitivity of 40.0% and a specificity of 87.2% in this regard.

CONCLUSIONS

In preparation for nephron-sparing surgery of renal cell carcinoma, neither preoperative routine imaging, nor intraoperative ultrasound can safely predict multifocal lesions of renal cell carcinoma.

Perisphincteric injection of botulinum toxin type A. A treatment option for patients with chronic prostatic pain?

BACKGROUND

Chronic prostatic pain is still a diagnostic and therapeutic problem. The clinical observation that prostatic and pelvic pain is accompanied by motoric and sensoric disorders of the pelvic floor muscles led to the hypothesis that prostatic pain roots in a changed processing of afferent and efferent information with the central nervous system (CNS).

METHODS

Neuro-urological work-up of 11 male patients with chronic prostatic pain was completed. This included a clinical evaluation of pelvic floor function, urodynamic investigation of bladder and urethra function and a cystoscopy to exclude morphological aberrations. A transurethral perisphincteric injection of 200 units botulinum toxin type A (BTX) was followed by a 2- to 4-week visit to evaluate their influence on the neuro-urological symptomatology.

RESULTS

All chronic prostatic pain patients suffered from a pathological pelvic floor tenderness, an inability of sufficient conscious pelvic floor control, a urethral hypersensitivity/hyperalgesia and a urethral muscle hyperactivity. Basic parameters of bladder function (capacity, sensitivity, compliance) were normal. The BTX injection was followed by a pelvic floor muscle weakening and a relief of prostatic pain and urethral hypersensitivity/hyperalgesia. A botulinum-related decrease of the functional urethral length, the urethral sphincter closure pressure, the postvoid residual volume and an increase of the peak and average uroflow were objectivated.

CONCLUSION

A weakening of the urethral sphincter muscle via blocking acetylcholine release by BTX injection is followed by pain relief and symptom improvement. It can therefore be concluded that a barrage of nociceptive information from the dysfunctional pelvic floor overflood the CNS and induce a changed CNS processing. Interrupting the efferent branch of the disturbed central circle is one opportunity to treat chronic prostatic pain.

Central nervous system neurons labeled following the injection of pseudorabies virus into the rat prostate gland

BACKGROUND

The human prostate gland plays an important role in male fertility and is involved in different functional pathologies of the male lower urinary tract (LUT). The role of the prostate in these medical disorders is mainly unknown. Traditional surgical therapeutic attempts often fail to help these patients. For years, the clinical sciences have been stagnating due to a lack of basic science knowledge. Investigations into neuroanatomy and neurophysiology are urgently needed. Therefore, the neuroanatomy of the prostate gland in an experimental setup was explored. Recent progress in neuroscience methodology allows a transneuronal tracing by using a self-amplifying virus tracer, pseudorabies virus (PRV).

METHODS

Sixty-two individual adult male Sprague-Dawley rats were used for retrograde transneuronal mapping of the spinal cord and brain stem after PRV-injection and control experiments. A PRV-tracer (5 microl, 1 x 10(8) pfu/ml) was injected into the prostate gland. After a survival time of 72, 96, or 120 hr, the animals were sacrificed. Brain and spinal cord were harvested via a dorsal laminectomy. After cutting on a freezing microtome, the tissue was immunostained for PRV.

RESULTS

PRV-positive cells were found within the sacral (S1-S2) and the thoracolumbar (T13-L2) spinal cord. At the supraspinal level, positive cells were found within the following regions: nucleus raphe, lateral reticular formation, nucleus gigantocellularis, A5 noradrenergic cell region, locus coeruleus, pontine micturition center, hypothalamus, medial preoptic region, and periaquaductal gray.

CONCLUSIONS

This is the first investigation on the central innervation of the prostate gland showing a broad central representation of neurons involved in the control of the prostate gland. It is obvious, comparing data from the literature, that there is a broad overlap in the innervation of pelvic visceral organs (bladder, rectum, and urethra). The appreciation of these neuroanatomical circumstances allows a growing understanding of common urological pathologies within the pelvis (pelvic pain, lower urinary tract, and bowel dysfunction).

Where are the limits of elective nephron- sparing surgery in renal cell carcinoma?

OBJECTIVES

The indication for elective nephron-sparing surgery (NSS) in renal cell carcinoma (RCC) is still controversial. The presented study was performed to determine limitations for NSS regarding to multifocality and to characterize the biological importance of these small tumor lesions.

METHODS

In 372 patients who underwent radical nephrectomy for RCC consecutively, nephrectomy specimens were investigated by using 3-mm parenchyma sections regarding to local tumor spread and multifocality. To characterize multifocal tumors, we performed cytogenetic and molecular genetic investigations.

RESULTS

Serial sections of 372 nephrectomy specimens revealed a total of 92 multifocal tumors in 61 specimens (16.4%). The correlation between tumor size and multifocality is shown as follows: tumor diameter 1-20 mm: 12.5%; 21-30 mm: 23.4%; 31-40 mm: 10.2%; >40 mm: 16.7%. The mean diameter of the multifocal tumors was 8.8x9.1x6.1 mm and the mean distance to the primary tumor was 26.4 mm (5-84 mm). Using cytogenetic and molecular genetic analysis, in nearly one third of all cases a concordance of chromosomal aberrations in primary and secondary tumors was found.

CONCLUSIONS

Multifocality of renal cell carcinoma occurs independently from primary tumor size. The evidence of structural and/or numeric aberrations, found in additional tumor foci, obviously is an argument for their malignant potential. This findings have to be considered in preparation of nephron-sparing surgery for patients with renal cell carcinoma.

Area density of smooth muscle cells and response to endothelin 1 in human hyperplastic prostate

BACKGROUND

alpha-Agonists and endothelins (ETs) are the only agents that have been proved to induce significant contraction of the prostate. Although the response to phenylephrine (PE) is dependent on the quality of smooth muscle (SM) within the prostate, it is not clear whether the response to ET-1 is also influenced by SM density. We evaluate the relationship between contractile responsiveness to ET-1 and the area density of SM of the human prostate.

MATERIALS AND METHODS

Specimens were obtained from 17 patients with prostatic hyperplasia that underwent transurethral resection of the prostate. Specimens were used for isometric tension study (PE, KCl and ET) and also for quantitative morphometric analysis.

RESULTS

PE and ET-1 induced dose-dependent contractile responses. There were no significant differences in the average maximum response (E(max)) to these two agents. E(max) to KCl and PE showed direct positive correlations with the area density of SM. E(max) to ET-1 also showed a positive correlation with the SM density, although this relationship was weaker than those for the other two agents. Moreover, there was a strong positive relationship between E(max) to PE, KCl and that to ET-1.

CONCLUSIONS

The area density of SM appeared to significantly influence the contractile response to ET-1 as well as the response to PE and KCl.

A study of pelvic floor function pre- and postradical prostatectomy using clinical neurourological investigations, urodynamics and electromyography

OBJECTIVES

Incontinence after radical prostatectomy is addressed to sphincter damage and/or bladder dysfunction. Taking into account a high cure rate of incontinence by pelvic floor biofeedback treatment, the search for further mechanisms of a complex physiological concept seems feasible.

METHODS

To characterize pelvic floor function, 18 patients were prospectively evaluated before and after radical prostatectomy by clinical neurourological tests, urodynamics and needle/surface electromyography (EMG).

RESULTS

In all patients (mean age 62 years) investigations were completed successfully. The outcomes of neurourological investigations (sacral reflexes, voluntary pelvic floor contraction and relaxation) and needle EMG showed no significant changes in the pre-/postoperative comparison. Only by using surface EMG polygraphy change of activation patterns during pelvic floor contraction (decreased mean and medium frequency) could be found.

CONCLUSION

In patients without preexisting bladder dysfunction and with a basically normal operative and postoperative course, fine motoric changes of pelvic floor function are the main finding. This cannot be explained by a pure anatomical approach. Neurophysiological events, like a barrage of nociceptive information, caused by surgical dissection and an inflammatory reaction due to the healing process, contribute to altered processing within the central nervous system. The appreciation of these mechanisms, well studied in neuroscience and pain research, offers a better understanding of surgery-related short- and longterm morbidity after pelvic surgery, i.e., urinary incontinence and erectile dysfunction.

Sacral nerve stimulation and diurnal urine volume

OBJECTIVES

During a screening trial to determine candidacy for sacral nerve stimulation (SNS), several patients were required to repeat the baseline dietary because of discrepancies in the 24-hour urine output before and after successful stimulation. This raised a question regarding the relationship between urine production and neuromodulation. A more complete diary analysis of patients affected by urgency/frequency and/or urge incontinence was therefore carried out to evaluate the possibility of a direct modulatory influence of SNS on urine production.

METHODS

Voiding diaries of 40 patients (37 females and 3 males, average age 39.4 years) who underwent SNS were evaluated. Voiding diaries were obtained at baseline, during and after peripheral nerve evaluation (PNE) and after permanent implantation.

RESULTS

There was an increase in the average volume/void during PNE in 39 patients. Twenty-four-hour urine volume during PNE was statistically greater than that at baseline. Volume/void and diurnal volume were also significantly greater in follow-up periods after permanent implantation.

CONCLUSION

SNS appears to influence not only bladder function but also urine production. Increase in volume/void is paralleled by an increase in 24-hour urine output. The mechanism is unclear, but it is consistent with an altered release of antidiuretic hormone. This observation reflects the direct refractory involvement of the hypothalamus in micturition.

Effective analgesia for extracorporeal shock wave lithotripsy: transcutaneous electrical nerve stimulation

OBJECTIVES

Extracorporeal shock wave lithotripsy (ESWL) has revolutionized the treatment of urinary stone disease. However, the most appropriate analgesia offering pain-free treatment, minimal side effects, and adequate cost effectiveness remains to be established. This prospective study was performed to evaluate the efficacy of transcutaneous electrical nerve stimulation (TENS) during ESWL using third-generation lithotripters.

METHODS

Two pairs of stimulator electrodes were placed paravertebrally at L1 and near the lithotripter shock tube before ESWL. Treatment was carried out as follows: (a) shock wave administration was begun (no current = sham TENS); (b) in the case of severe pain, TENS was begun; and (c) if patients experienced no pain relief, analgesic drugs were given intravenously.

RESULTS

Of 149 patients, 92 (62%) did not need any analgesia (neither TENS nor medication). In 42 (72%) of the remaining 57 patients, a TENS-related, pain-relieving response was observed. ESWL-induced pain could be reduced by 39.2%. The degree of fragmentation assessed by two urologists was found to be 90% for patients receiving TENS compared with a retrospectively analyzed control group (94%, n = 100).

CONCLUSIONS

Two different theories explaining TENS-related analgesia are known: segmental (spinal) and supraspinal (central) inhibition. Since we did not observe any analgesic effect in patients having both pairs of electrodes attached around the shock tube (n = 30), supraspinal inhibition obviously accounts for the abovementioned pain relief. We conclude that TENS is a noninvasive, cost-effective method to achieve side-effect-free analgesia in ESWL using third-generation lithotripters.

Real indications for adrenalectomy in renal cell carcinoma

OBJECTIVES

Adrenalectomy is a part of radical nephrectomy because of the surgical oncology principle of a 'wide margin beyond the malignancy' and due to concern over possible metastases to the ipsilateral adrenal gland, especially in upper pole tumors. But, neither the frequency, predisposing factors of the renal cell carcinoma nor mechanisms of involvement of the adrenal gland are well defined. We assessed the ipsilateral adrenal involvement in renal cell carcinoma to determine whether ipsilateral adrenalectomy during radical nephrectomy is essential.

MATERIAL AND METHOD

In a series of 15,347 autopsies in Jena from 1985 through 1996, 272 renal cell carcinoma with 24 adrenal metastases were found. In the same period 9 adrenal metastases were found in 639 radical nephrectomies. Contralateral and bilateral metastases were seen in 15 cases of the autopsy series and in 2 cases of the operative series.

RESULTS

The risk of adrenal metastases correlated with multifocal tumors, pleomorphic cell type, anaplastic growth pattern and tumors that were larger than 2.5 cm. Of the 24 renal cell carcinomas with adrenal metastases in the autopsy series, 23 had evidence of widespread disease and 22 had lymph node metastases. A preoperative abdominal computerized tomography was performed in all 9 patients of the operative series with renal cell carcinoma and adrenal involvement. The adrenal gland was considered abnormal in 8 of the 9 cases (88.9%). Only in 1 patient was the computerized tomography incorrectly interpreted as negative.

CONCLUSION

We think adrenalectomy should only be performed if there is radiographic evidence of metastases in the adrenal gland or adrenal infiltration by a large upper-pole tumor is possible. Macroscopically normal adrenal glands should not be removed during tumor nephrectomy because the need and benefit of routine adrenalectomy are extremely limited.

Neurourological insights into the etiology of genitourinary pain in men

PURPOSE

Pelvic pain remains a challenging urological problem. Because antimicrobial therapy is often unsuccessful for relieving symptoms, it is reasonable to question whether pelvic pain is the result of microbiological versus functional pelvic disease. We analyzed clinical and urodynamic findings to evaluate the role of pelvic floor dysfunction in patients with pelvic pain.

MATERIALS AND METHODS

We retrospectively evaluated history, physical examination and urodynamic studies in 103 men with an average age of 47 years who presented with pelvic pain between August 1994 and August 1997. In all patients microbiological tests were negative before study entry.

RESULTS

The reported locations of pain were the prostate and/or perineal region in 45.6% of cases, scrotum and/or testis in 38.8%, penis in 5.8%, bladder in 5.8%, and lower abdomen and lower back in 1.9% each. Previous treatment consisted of 1 to 12 courses of antibiotics in the preceding 6 to 36 months. In 88.3% of the patients there was pathological tenderness of the striated muscle with poor to absent pelvic floor function. Urodynamics were performed in 84 cases. Cystometry was normal except for decreased compliance in 5 patients. Abnormal findings were mostly evident in the coordination of voiding and in dynamic sphincter-pelvic floor activity. Average sphincter pressure was increased to 104.9 cm. water in 72.6% of the patients, average peak urine flow was decreased to 9.9 ml. per second in 61.9% and functional urethral length was increased to greater than 35 mm. in 79.8%. Urethral profile pattern was dysfunctional, obstructed, and combined dysfunctional and obstructed in 52.4, 11.9 and 21.4% of the cases, respectively, while in 88.1% urethral sensitivity was minimally or markedly increased.

CONCLUSIONS

Since activity is a reflection of neural control, the apparent association of pelvic floor dysfunction with pelvic pain raises the probability of a primary or secondary central nervous system breakdown in the regulation of pelvic floor function. This hypothesis is supported by the improvement in symptoms caused by therapy aimed at modulating the pelvic floor, such as biofeedback, medication and sacral anterior root stimulation.

Effects of estrogen and progesterone on urinary bladder in female rabbit: evaluation by quantitative morphometric analysis

OBJECTIVES

To investigate possible effects of estrogen and/or progesterone on the histologic characteristics of female rabbit urinary bladders, we carried out quantitative morphometric analysis of the rabbit bladders.

METHODS

Mature female rabbits were treated by ovariectomy with and without successive estrogen and/or progesterone administration. Area densities of the connective tissue (CT) and smooth muscle (SM) cells, the area of single SM cells, and the thickness of the bladder wall were determined by computer-assisted quantitative morphometric analysis.

RESULTS

Six weeks after each treatment, ovariectomy alone resulted in a decrease in CT density of the bladder. Successive estrogen treatment increased the bladder wet weight and SM cell density within the bladder wall. Progesterone treatment reduced CT degradation in ovariectomized rabbits. Sex steroids did not significantly influence the area of each SM cell. There was no significant difference in histologic characteristics between the rabbits treated by estrogen alone and those treated by combination (estrogen and progesterone) therapy.

CONCLUSIONS

Ovariectomy and successive hormonal replacement therapy resulted in morphologic changes within the rabbit urinary bladder. Cotreatment with progesterone did not significantly change the morphologic findings produced by estrogen treatment alone.

Central autonomic innervation of the lower urinary tract--a neuroanatomy study

Knowledge about the central innervation of the lower urinary tract is limited. The spinal cord and the pontine micturition center have been investigated most thoroughly, whereas high centers have received little attention. Pseudorabies virus (PRV), a self-amplifying and transneuronal tracer was injected into the bladder trigone of 21 Sprague-Dawley rats. The animals were killed after 72, 96, and 120 h. The whole CNS was sectioned and immunostained for PRV. CNS centers directly connected to the bladder include the intermedio lateral cell column, the central autonomic nucleus, and the nucleus intercalatus at the spinal cord levels T12-L2 and L6-S2. The raphe pallidus et magnus, the A5 nor-adrenergic area, the pontine micturition center, the locus coeruleus, the periaquaductal gray, the nucleus para- et periventricularis of the hypothalamus, the red nucleus, the medial preoptic area, and the cortex are supraspinal centers connected to the bladder. Lower urinary tract function is a complex multilevel and multineuronal interaction. It involves facilitation and inhibition at many levels of the CNS.

Botox-induced prostatic involution

BACKGROUND

A simple approach to induced prostatic atrophy was explored. Surgical denervation is known to produce profound atrophy of the rat prostate. Because Botulinum toxin type A (Botox) produces a long-term chemical denervation, the potential to induce atrophy of the rat prostate was explored.

METHODS

Thirty rat prostates were injected with varying doses of Botox. Single and serial injections were used, and rats were subsequently sacrificed after either 1 or 4 weeks, respectively. The prostate glands were harvested, weighed, and histologically studied for morphologic and apoptotic changes.

RESULTS

The total prostate volume and weight were found to be reduced in all Botox-injected animals. Histologically, a generalized atrophy of the glands was observed with the H&E stain. There was also diffuse glandular apoptosis evident with the Tunel stain. There were no significant complications (e.g., urinary retention, weight loss, or hind/limb weakness).

CONCLUSIONS

Botulinum toxin type A injection into the prostate gland induces selective denervation and subsequent atrophy of the prostate. Apoptosis was seen diffusely throughout the gland. It may be possible that in the future, this long-acting neurotoxin could be used for the treatment of common pathologies of the human prostate.

Increased transforming growth factor beta1 plasma level in patients with renal cell carcinoma: a tumor-specific marker?

PURPOSE

The most worrying problem with renal cell carcinoma (RCC) seems to be the prediction of metastases by means of tumor-specific markers. Therefore, much effort is committed to the development of new markers.

MATERIALS AND METHODS

The level of latent transforming growth factor beta1 (TGF-beta1) was measured in plasma samples by ELISA. These samples were collected from patients with RCC before they underwent radical nephrectomy, from patients 1 h after extracorporeal lithotripsy, from patients with pyelonephritis, and from healthy controls.

RESULTS

In all cases of RCC the levels of latent TGF-beta1 in plasma were much higher (n = 20, 41.0 +/- 13.9 ng/ml, range 19.3-78.1 ng/ml) than in healthy controls (n = 20, 3.8 +/- 2.9 ng/ml, range 0.6-9.9 ng/ml, p < 0.0001). The TGF-beta1 levels in plasma after extracorporeal lithotripsy (n = 20, 7.4 +/- 4. 64 ng/ml, range 2.9-21.7 ng/ml, p < 0.01) and in patients suffering from pyelonephritis (n = 20, 18.93 +/- 14.2 ng/ml, range 4.2-46.7 ng/ml, p < 0.001) were also higher than in healthy controls.

CONCLUSION

We conclude that increased levels of latent TGF-beta1 are common in the plasma of RCC patients. The TGF-beta1 plasma level in RCC was found to be significantly higher than in cases of inflammation. Thus, TGF-beta1 is a possible tumor-prognostic marker in RCC.

Postoperative chronic pain and bladder dysfunction: windup and neuronal plasticity--do we need a more neurological approach in pelvic surgery?

PURPOSE

Cases of combined symptoms of dysfunctional voiding and associated pelvic discomfort are difficult diagnostic and therapeutic challenges. Surgical solutions not uncommonly fail to relieve those symptoms. We determine why these symptoms persist postoperatively.

MATERIALS AND METHODS

Four cases of ureteral injury during gynecological laparoscopic procedures for pelvic/menstrual pain are presented. The cases are reviewed for their severity and similarity in presenting symptoms, complications and long-term consequences.

RESULTS

In all cases light pain symptoms and/or dysfunctional voiding problems that existed before the initial surgery escalated severely after corrective pelvic surgery.

CONCLUSIONS

There are established neurophysiological mechanisms that would explain the observed increase in pain after surgical manipulation of the pelvis. Windup and changes in neuronal plasticity are direct consequences of wounding and/or neural injury to the central nervous system. These principles are important for surgeons to appreciate due to the impact they can have on the outcomes of surgery. Blocking the sensory input into the spinal cord, inherent to every surgical procedure, through use of local anesthetics, that is preemptive anesthesia, before creation of a wound provides the greatest protection against escalation of symptoms. Thorough evaluation of all patients before pelvic surgery is recommended to identify high risk groups (preexisting pain, voiding syndromes).

Ceramic coagulation tip for interstitial thermoablation of the prostate: first experiments

A direct electrically heated ceramic coagulation tip for interstitial thermoablation has been developed. Both the coagulation tip and a laser system (Medilas 4060) were tested in vitro to compare their efficacies. We have obtained coagulation necroses of similar sizes. The electrical coagulation tip as opposed to laser coagulation is a new therapeutic option for the therapy of high risk patients with symptomatic benign prostatic hyperplasia. Because of the materials used and the principle of heating involved, certain economic and safety advantages over the laser system are offered.

[EMG surface polygraphy of the pelvic floor--description of functional changes after radical prostatectomy]

Urinary stress incontinence after radical prostatectomy could be cured by physiotherapy in a high percentage. The authors developed an investigation procedure for description of myoelectrical activity of pelvic floor with surface electrodes. 10 patients were studied 1 day before, 10 days and 6 months after radical prostatectomy. Significant changes of amplitude and frequency characteristics could not be found in rest and during the stationary intervals of maximal contraction. But after the operation in all patients changed the activation pattern within the interval of increasing muscle contraction. The mean and median frequency decreased significantly (Friedman-test, p < 0.001). This was interpreted as a problem of intramuscular coordination. After physiotherapy urinary incontinence was cured or improved. The typical activation pattern of dyscoordination was not more evident after 6 months.

Strangulation of the scrotum

A man presented to our department showed scrotal swelling and beginning priapism due to a ball bearing ring. The patient had passed his scrotum through the metal ring eight years before. Now he has observed an increasing swelling for seven days. The condition had to be treated operatively.

[Implants in urology]

During the past three decades, the use of implants both in urology and other surgical specialties has experienced exponential growth. The development of implantable genitourinary prostheses has similarly grown from simple testicular substitutes to the large group of implantable penile prostheses, artificial urinary sphincters, prostheses in neurology, and possible future developments of artificial bladder and ureteral materials. The majority of urologic prostheses are constructed of silicone, because it is relatively inert, but nevertheless silicone causes some local tissue reactions and deteriorates with time. Currently, much research is underway studying the effects on the human host. Although multiple mechanical malfunctions of these prosthetic devices have occurred, periprosthetic infection is the most disastrous complication which usually leads to removal of the prostheses. This article gives the clinician an overview of common complex urologic implants, especially the current development of prostheses in the field of neurology.

[Analysis of primary management of bladder malfunction in traumatic paraplegic patients]

Intermittent catheterisation is the demanded therapy of bladder paralysis during the spinal shock. We investigated the realisation of this concept. In 1994 after first treatment in other hospitals 97 patients were treated in the Thuringian Spinal Cord Centre Sülzhayn. The primary treatment of the paralysed bladder was: indwelling catheter: 44 patients (45.4%), suprapubic catheter: 30 patients (30.9%). Only 15 patients (15.5%) were catheterized intermittently. No urological treatment was carried out in seven cases.

CONCLUSION

The primary treatment of bladder analysis in spinal cord injured patients has to be improved.

Diagnostic value of natural fill cystometry in neurogenic bladder in children

OBJECTIVE

Investigation of the diagnostic value of natural fill cystometry (NFC) in children with neurogenic bladder in comparison to conventional videocystometry (CVC).

METHODS

We investigated 20 children (aged 6-11; 15 girls and 5 boys) with the following diagnoses: 6 myelomeningocele, 2 tethered cord syndrome, 1 syringomyelia, 1 Vater syndrome, 1 suprasacral spinal cord injury, 9 suspected neurogenic bladder. We carried out a NFC after completing standard diagnostic including a slow-filling CVC.

RESULTS

All investigations were completed successfully. The investigation lasted 6-20.5 h (mean 11:15 h). We registered phases of sleep, waking consciousness and micturition. CVC findings were confirmed in 45%: normal bladder function was confirmed in 2 patients (10%), bladder hyperactivity was confirmed in 7 patients (35%). In 55% we obtained different findings on NFC in comparison to the slow-filling CVC: bladder hyperactivity was not confirmed in 2 (10%), detection of bladder hyperactivity was found in 4 children (20%) with normal bladder function on CVC, detection of bladder hyperactivity on NFC was found in 5 children (25%) with low-compliance bladder on CVC. In 45% of all children, NFC detected new findings compared with CVC diagnoses. In 10%, possible artifacts (e.g. due to catheterization) of CVC were recognized. CVC findings were confirmed in 45%.

CONCLUSION

These results are preliminary but they suggest that this is a new diagnostic method for improving the diagnostic standard in the childhood neurogenic bladder.

[Possibilities of therapy and rehabilitation of patients with urinary incontinence]

Rehabilitation of incontinent patients is an interdisciplinary challenge. Many therapeutical options in gynecological urology reveal an optimal rehabilitation of these patients. In the last years, a great scientific progress in the area of neurourology offers patients with severe dysfunction of the lower urinary tract (e.g. spinal cord injury) new concepts to improve their urological problems.

[Injuries to the external male genitals]

Genital injuries are rare in comparison to other traumatologic injuries. Diagnostic and therapy demand a detailed urological knowledge and high abilities in the surgical and the microsurgical field. The emergency doctor/urologist, who firstly treats the patient, decides about the therapeutic outcome. Delays in the diagnostic procedures and false therapeutic indications may be followed by impairments in cosmetic and function of the genitale for the patient. Therefore, we demand an early consultation of an urologist.

[The high risk patient with symptomatic prostatic hyperplasia--a therapeutic dilemma?]

Since a few year, a lot of new methods in therapy of symptomatic benign prostate hyperplasia are available. Until now, none of these methods could reach the outcome of surgical therapy. Therefore, surgery is remaining the golden standard in the therapy of BPH. Alternative methods are of great importance in the treatment of "high risk patients". It may be possible to improve the quality of life. Laser therapy and intraurethral catheters are superseding transurethral and suprapubic catheters. The indication for the several methods has to been proven critically.