[High urinary diversion after irradiation to the lesser pelvis]

As useful and necessary as radiotherapy may be, it is associated with irreversible long-term adverse effects including loss of bladder function. In the majority of cases the small bowel, sigmoid rectum and ureter are also affected. The extent of injury depends on the irradiated area, the applied dose and the quality of application. Three factors are essential when choosing a urinary diversion: the length of functional ureter, the position of the bowel outside of the irradiated area and the type of diversion. A continent diversion is best performed through a ascending-transverse or transverse-descending colon pouch. The efferent segment is diverted through the umbilicus. The simplest technique for an incontinent diversion is a conduit using the ascending colon or the right colon flexure. If the length of the ureter does not suffice for such a conduit, the ideal solution is a transverse conduit, as this conduit can be attached to both renal pelves, while simultaneously allowing free choice of the lateral location of the stoma. In case of an exenteration, a double stoma on one side of the body should be avoided in order to prevent maintenance issues.

[Plastic reconstruction of external genitalia after Fournier's gangrene]

Fournier's gangrene is a rapidly progressing necrotizing fasciitis restricted to the perineal and genital regions. Although rare, it is an acute life-threatening disease, requiring rapid radical surgical debridement and antibiotic treatment, resulting in large soft tissue defects. Various reconstructive methods for defect coverage are applied to satisfactorily reconstitute functionality and esthetics.

[Influence of Comorbidity on Mortality and Morbidity in the Radical Cystectomy for Bladder Cancer]

Radical cystectomy (RC) with bilateral pelvic lymph node dissection constitutes the gold standard treatment for muscle-invasive and high-risk non-muscle-invasive urothelial carcinoma of the bladder refractory to instillation therapy. Although radical cystectomy is performed with curative intent, the overall 5-year survival has been reported to be as low as 62% in the current literature. Various clinico-pathological parameters determine post-RC outcome, but besides these, the role of comorbidity has gained increasing attention and can be quantified with various comorbidity scores. We here review the most recent data on comorbidity scores and performance indices, which have been assessed in patients, undergoing RC and highlight their clinical implications.

Computed tomography after nephron-sparing surgery

The increased use of abdominal cross-sectional imaging has contributed to a greater detection of incidental small renal masses. Treatment options for localized disease renal cell carcinoma include radical nephrectomy or partial nephrectomy (PN), the former being preferred for treatment of early-stage tumors. The most adopted technique for follow-up imaging is contrast-enhanced computed tomography (CT), whose findings can cause uncertainty and unnecessary repetition of examinations. Our purpose is to describe CT findings after PN and to describe evolution in time of such images.

[Henoch-Schönlein purpura resulting in an obstructive bladder mass]

Henoch-Schönlein purpura (HSP) is the most common form of an immunological systemic vasculitis of childhood. The classic clinical symptoms include purpuric rash, abdominal pain, arthralgias, and haematuria, but the spectrum of HSP may vary to very rare forms. This article reports on an 8-year-old girl with a Henoch-Schönlein purpura (HSP) which resulted in an obstructive bladder mass and subsequent urinary retention. This is the first case reported in the literature, describing such a course.

[Does the surgeon have an influence on clinical voiding parameters and postoperative sexual function after TURP?]

BACKGROUND

Benign prostate syndrome (BPS) is a common phenomenon in the aging male. Transurethral resection of the prostate (TURP) remains the international standard of care for -patients requiring surgical intervention for BPS. Although the voiding improvement following TURP is well-documented, controversy exists regarding its effect on post-operative sexual function. In this study we investigated the possible influence of individual surgeons on clinical voiding parameters and post-operative sexual function after TURP.

PATIENTS/MATERIALS AND METHODS

We analyzed 123 patients with a mean age of 70 years (46-88 years) who had undergone TURP secondary to BPS. To evaluate the clinical parameters, patients completed the IPSS and IIEF-15 questionnaires preoperatively and 1 year postoperatively. Additional parameters including urinary flow and post voiding residual volume were also collected.

RESULTS

A statistically significant improvement in voiding function was noted postoperatively. The mean IPSS improved from 19.35 to 6.49 (p<0.05). Objective flow parameters also improved; Qmax 10.43-19.46 mL/s (p<0.05) and residual volume 95-11 mL (p<0.05). The mean pre-operative prostate volume was 41.8 cm³. The mean resected tissue weight was 21.1 g. The pa-tients showed no significant change in the frequency of their sexual activity following TURP, however IIEF-15 sexual function and erectile function scores declined mildly. This was statistically significant with pre-op IIEF-15=30.52 and post-op 26.24 (p<0.05). Comparing individual surgeons, no statistically significant difference was noted in IPSS and IIEF-15 functional outcome scores. Although significant differences existed in the total amount of resected tissue, the percentage of resected adenoma in relation to total prostate volume was not statistically significant.

CONCLUSION

Overall, IPSS scores improved significantly following TURP and sexual function scored declined mildly. We detected no influence between surgeons on clinical voiding parameters and postoperative sexual function after TURP using the IPSS and IIEF-15 questionnaires.

Accuracy of the EORTC risk tables and of the CUETO scoring model to predict outcomes in non-muscle-invasive urothelial carcinoma of the bladder

Background:

The European Organization for Research and Treatment of Cancer (EORTC) risk tables and the Spanish Urological Club for Oncological Treatment (CUETO) scoring model are the two best-established predictive tools to help decision making for patients with non-muscle-invasive bladder cancer (NMIBC). The aim of the current study was to assess the performance of these predictive tools in a large multicentre cohort of NMIBC patients.

Methods:

We performed a retrospective analysis of 4689 patients with NMIBC. To evaluate the discrimination of the models, we created Cox proportional hazard regression models for time to disease recurrence and progression. We incorporated the patients calculated risk score as a predictor into both of these models and then calculated their discrimination (concordance indexes). We compared the concordance index of our models with the concordance index reported for the models.

Results:

With a median follow-up of 57 months, 2110 patients experienced disease recurrence and 591 patients experienced disease progression. Both tools exhibited a poor discrimination for disease recurrence and progression (0.597 and 0.662, and 0.523 and 0.616, respectively, for the EORTC and CUETO models). The EORTC tables overestimated the risk of disease recurrence and progression in high-risk patients. The discrimination of the EORTC tables was even lower in the subgroup of patients treated with BCG (0.554 and 0.576 for disease recurrence and progression, respectively). Conversely, the discrimination of the CUETO model increased in BCG-treated patients (0.597 and 0.645 for disease recurrence and progression, respectively). However, both models overestimated the risk of disease progression in high-risk patients.

Conclusion:

The EORTC risk tables and the CUETO scoring system exhibit a poor discrimination for both disease recurrence and progression in NMIBC patients. These models overestimated the risk of disease recurrence and progression in high-risk patients. These overestimations remained in BCG-treated patients, especially for the EORTC tables. These results underline the need for improving our current predictive tools. However, our study is limited by its retrospective and multi-institutional design.

Validation of RiskCheck Bladder Cancer ©, version 5.0 for risk-adapted screening of bladder cancer

INTRODUCTION

The aim of the study was to assess the strength of the online tool RiskCheck Bladder Cancer©, version 5.0 (RCBC) for early detection of bladder cancer (BC).

MATERIALS AND METHODS

RCBC was evaluated retrospectively based on the data of 241 patients, of which 141 were suffering from BC. Statistical analysis was performed by descriptive statistics, nonparametric group comparison, classification tree analysis and ROC analysis.

RESULTS

ROC analysis of the risk classification showed a sensitivity of 71.6%, a specificity of 56.5%, a positive predictive value of 67.8%, a negative predictive value of 52% and an accuracy of 63.5%. BC risk factors ranked by importance are time of smoking (p < 0.0001), gender (within the nonsmoking group: p < 0.009), occupational toxin exposure (within the group <35 years of smoking: p < 0.048) and amount of consumed cigarettes resulting in a 95% association with BC (within the group >35 years of smoking: p < 0.0001).

CONCLUSIONS

The high predictive power of RCBC for the identification of asymptomatic patients living under risk could be demonstrated.

[Oral mucosa for reconstructive urethral surgery]

The use of oral mucosa for urethral stricture repair has become the standard approach in reconstructive urethral surgery. Compared to other tissues oral mucosa shows several advantages, such as simple harvesting, good urine tolerance and low harvesting morbidity. For defects of the male bulbar urethra measuring 2 cm or longer, urethral reconstruction with oral mucosa is the procedure of choice. The oral mucosa graft can be used as an inlay or as an onlay graft. Most repairs can be completed in one stage but for complex strictures two stages are needed.

Risk stratification of pT1-3N0 patients after radical cystectomy for adjuvant chemotherapy counselling

BACKGROUND

In pT1-T3N0 urothelial carcinoma of the bladder (UCB) patients, multi-modal therapy is inconsistently recommended. The aim of the study was to develop a prognostic tool to help decision-making regarding adjuvant therapy.

METHODS

We included 2145 patients with pT1-3N0 UCB after radical cystectomy (RC), naive of neoadjuvant or adjuvant therapy. The cohort was randomly split into development cohort based on the US patients (n=1067) and validation cohort based on the Europe patients (n=1078). Predictive accuracy was quantified using the concordance index.

RESULTS

With a median follow-up of 45 months, 5-year recurrence-free and cancer-specific survival estimates were 68% and 73%, respectively. pT-stage, ge, lymphovascular invasion, and positive margin were significantly associated with both disease recurrence and cancer-specific mortality (P-values ≤ 0.005). The accuracies of the multivariable models at 2, 5, and 7 years for predicting disease recurrence were 67.4%, 65%, and 64.4%, respectively. Accuracies at 2, 5, and 7 years for predicting cancer-specific mortality were 69.3%, 66.4%, and 65.5%, respectively. We developed competing-risk, conditional probability nomograms. External validation revealed minor overestimation.

CONCLUSION

Despite RC, a significant number of patients with pT1-3N0 UCB experience disease recurrence and ultimately die of UCB. We developed and externally validated competing-risk, conditional probability post-RC nomograms for prediction of disease recurrence and cancer-specific mortality.

Multiprobe fluorescence in situ hybridisation: prognostic perspectives in superficial bladder cancer

AIM

To establish independent prognostic factors on a chromosomal basis in superficial bladder cancer, using a multicolour fluorescence in situ hybridisation (FISH) probe mix.

PATIENTS AND METHODS

In 2002, voided urine from 75 consecutive patients (mean age 71.7, range 52-93) years under follow-up for superficial urothelial cancer was studied prospectively. The patients were observed for a mean (standard deviation (SD)) period of 39.3 (6.8) months (range 27-58) until July 2005. A multicolour FISH on liquid-based voided urinary cytology was carried out on all patients. Univariate analysis, using a log rank test, was used to determine the prognostic relevance of a low-risk pattern and a high-risk pattern. Progression-free survival time was calculated from the date of first diagnosis to first recurrence or progression according to the Kaplan-Meier product-limit method.

RESULTS

One patient was lost to follow-up. 27 of the 74 remaining (36.8%) patients showed recurrent disease. In 9 (33.3%) patients with a low-risk pattern disease recurred after a mean (SD) observation time of 29.7 (1.9) months (range 8.3-52.3, median 30.8 (12.4)). 18 (66.7%) patients with a high-risk pattern developed recurrence within a mean (SD) of 17.6 (2.0) months (range 4-38.8, median 16.7 (11.6)). The Kaplan-Meier curve for progression-free survival showed marked differences between the low-risk and the high-risk groups.

CONCLUSION

Patients with a high-risk chromosomal pattern have a markedly shorter disease-free survival time and higher progression rate than patients with a low-risk pattern. High-risk patients can therefore be treated more aggressively to prevent tumour spreading.

Liquid-based cytology as a tool for the performance of uCyt+ and Urovysion Multicolour-FISH in the detection of urothelial carcinoma

The aim of the study was to assess the value of liquid-based urinary cytology as a tool to perform uCyt+ and Multicolour-FISH in patients under follow-up after urothelial cancer. Therefore, standard cytology was compared to liquid-based cytology with the addition of the uCyt+ test, which traces the three monoclonal antibodies M344, LDQ10 and 19A211 in exfoliated urothelial cells; and Multicolour-FISH (including centromere-specific probes for chromosomes 3, 7, 17 and a locus-specific probe for 9p21/p16) performed on thin-layer specimens. UCyt+ showed an overall sensitivity of 86.2% and cytology of 45.0%. Overall sensitivity of both the tests combined was 90%. Sensitivity of Multicolour-FISH was 96.4%. All conventional cytology diagnoses were confirmed by liquid-based cytology. Liquid-based cytology is a valid tool for the performance of adjunctive analyses, such as uCyt+ and Multicolour-FISH, on residual cellular material.

Does extended lymphadenectomy increase the morbidity of radical cystectomy?

OBJECTIVE

To report the events during and after radical cystectomy and urinary diversion for bladder cancer, in terms of major and minor complications, comparing a minimal with an extended lymphadenectomy, as more lymph nodes obtained during radical cystectomy may improve staging and thus the outcome.

PATIENTS AND METHODS

We reviewed 92 consecutive patients who underwent radical cystectomy from March 1998 to February 2002; 46 had a minimal (group A) and 46 an extended lymphadenectomy (group B). Cases were selected according to the American Society of Anesthesiologists classification, only including those graded 2 or 3. We specifically evaluated the incidence and type of complications within 30 days after surgery.

RESULTS

Because of extending the lymphadenectomy the operative duration was a median of 63 min longer in group B (P < 0.01). Complications requiring surgical interventions occurred in four (9%) patients in group A and five (11%) in group B (P = 0.28). Complications requiring no surgical intervention were also similar in both groups. Three patients died, two in group A and one in group B (P = 0.57).

CONCLUSION

Extended lymphadenectomy in radical cystectomy does not increase the morbidity within 30 days of surgery.

Modified Laparoscopic Nephroureterectomy for Treatment of Upper Urinary Tract Transitional Cell Cancer Is Not Associated with an Increased Risk of Tumour Recurrence

INTRODUCTION

Laparoscopic nephroureterectomy reduces the morbidity of surgical management of urinary tract transitional cell carcinoma (TCC), but a potentially increased risk for local tumour spreading was reported. We evaluated results obtained from patients undergoing a modified laparoscopic approach and open procedures in this respect.

PATIENTS AND METHODS

Between January 2000 and March 2002 we performed 19 modified laparoscopic nephroureterectomies (LNU) with open intact specimen retrieval in conjunction with open distal ureter and bladder cuff removal and 15 open standard nephroureterectomies (ONU). Staging lymphadenectomy was performed in 14/19 (73.7%) patients with LNU and in 6/15 (40.0%) with ONU. In all patients operating time, blood loss, complications, pain score (VAS) and data in respect to tumour recurrence were analysed. Mean follow-up was 22.1+/-9.2 (range 14-34) months for LNU and 23.1+/-8.8 (14-36) for ONU respectively.

RESULTS

In LNU and ONU pathological features were 12 pT1 vs. 10 pT1, 2 pT2 vs. 2 pT2 and 5 pT3 vs. 3 pT3, respectively. All patients had TCC and were R0 at final histology. Four patients with LNU had lymph node involvement, one in ONU. LNU had decreased operating times (p=0.057), blood loss (p=0.018), complications (p=0.001) and VAS scores (p=0.001). One tumour recurrence occurred in LNU, associated with a pT3b pN2 G3 TCC at final histology. One patient with ONU had local tumour recurrence at the site of the bladder cuff. No port-site metastasis occurred during follow-up with LNU.

CONCLUSION

Improved peri-operative results and same cancer control as compared to open surgery by this modified LNU was not associated with an increased risk for tumour recurrence, since strict "non-touch" preparation, avoiding of urine spillage and intact specimen retrieval prevents tumour seeding. However, results from long term studies are still warranted to clarify this issue.

Detection of upper urinary tract transitional cell carcinoma with ImmunoCyt: a preliminary report

OBJECTIVES

To assess the clinical performance of ImmunoCyt in the detection of upper urinary tract transitional cell carcinoma (UT-TCC). This newly developed immunocytochemical test detects three cellular markers specific for TCC.

METHODS

Thirty-seven patients with symptoms and/or findings on imaging suggestive of UT tumors were prospectively evaluated. All patients underwent a standard cytologic evaluation and ImmunoCyt testing of voided urine, as well as imaging studies. Urine samples were also obtained from the UT of 32 patients by ureteral catheterization and tested by cytologic analysis and ImmunoCyt.

RESULTS

Sixteen patients had UT-TCC as documented by the final histologic evaluation. The sensitivity of testing the voided urine from 37 patients was 50% for cytologic analysis, 75% for ImmunoCyt, and 87% for both methods combined. The cytologic evaluation detected no G1, 1 (17%) of 6 G2, and 7 (100%) of 7 G3 tumors. ImmunoCyt detected 1 (33%) of 3 G1, 6 (100%) of 6 G2, and 5 (71%) of 7 G3 tumors. The sensitivity in the 32 urine samples obtained from the UT was 82% for cytologic analysis, 91% for ImmunoCyt, and 100% for both methods combined. Cytologic analysis detected all G2 and G3 (100% sensitivity) and no G1 tumors. ImmunoCyt detected 2 (100% sensitivity) of 2 G1, 4 (100%) of 4 G2, and 4 (80%) of 5 G3 tumors. The test specificity, calculated in 21 patients free of TCC, was 100% for cytologic analysis in voided and ureteral urine specimens and 95% and 100% for ImmunoCyt in voided and ureteral urine samples, respectively.

CONCLUSIONS

The results of this preliminary study show that ImmunoCyt complements cytologic analysis in detecting UT-TCC, mainly because of its high sensitivity to low-grade TCC. The combination of cytologic testing and ImmunoCyt gives 100% sensitivity in detecting UT-TCC in UT urine samples.

Dehydroepiandrosterone in the treatment of erectile dysfunction in patients with different organic etiologies

In 1994 the Massachusetts Male Aging Study described an inverse correlation of the serum levels of dehydroepiandrosterone sulfate (DHEAS) and the incidence of erectile dysfunction (ED). The positive results of a pilot study in the treatment in patients with no organic etiology prompted a detailed investigation on the efficacy of DHEA therapy for ED in patients with different organic etiologies, in a prospective study. The inclusion criteria included ED, a normal physical condition, normal serum levels of testosterone, prolactin and PSA and a serum DHEAS level < 1.5 micromol/l. The study patients comprised 27 patients (group 1) with hypertension, 24 patients (group 2) with diabetes mellitus, six patients with neurological disorders (group 3) and 28 patients (group 4) with no organic etiology were treated with 50 mg DHEA p.o. for 6 months. We assessed efficacy by using the responses to question 3 (frequency of penetration) and question 4 (maintenance of erections after penetration) of the 15-question International Index of Erectile Function (IIEF). DHEA treatment was associated with statistically significantly higher mean scores compared to baseline values for question 3 and question 4 of the IIEF in groups 1 and 4 after a period of 24 weeks. The differences between the mean scores of groups 2 and 3 and the baseline values were not statistically significant. Our results suggest that oral DHEA-treatment may be of benefit to patients with ED who have hypertension or to patients with ED without organic etiology. There was no impact of DHEA therapy on patients with diabetes mellitus or with neurological disorders.

Von Recklinghausen neurofibromatosis with urinary bladder involvement

von Recklinghausen neurofibromatosis is an autosomal dominant transmitted disease with 100% penetrance but variable phenotypic expression. The incidence of this systemic disease is 1 in 3000 live births; however, genitourinary manifestations are rare. We report on our management of 1 case during the past 16 years.

Lymphatic drainage of prostatic transition and peripheral zones visualized on a three-dimensional workstation

OBJECTIVES

To determine whether the prostate has lymphatic/lymph node drainage that is not sampled by conventional lymphadenectomy and whether the transition and peripheral zones of the prostate have a different lymphatic drainage, because up to one quarter of lymph-node-negative patients who undergo radical prostatectomy will develop distant metastases.

METHODS

Ten patients (mean age 62.3 years, range 50 to 76) scheduled for transrectal ultrasound-guided sextant biopsy because of an elevated serum prostate-specific antigen level of 4 to 10 ng/mL and a normal digital rectal examination were included in this study. All patients underwent ultrasound-guided sextant biopsies. Subsequently, an oily contrast medium was injected into the transition zone (group A, n = 5) or peripheral zone (group B, n = 5) of the prostate under transrectal ultrasound guidance and fluoroscopy. Immediately, 1 hour, and 24 hours after the procedure, anteroposterior and lateral radiographs were obtained. In addition, spiral computed tomography of the abdomen was performed 10 minutes after the procedure and analyzed on a three-dimensional workstation.

RESULTS

No difference in the lymphatic drainage system between the transition and peripheral zones of the prostate was found. In all patients (n = 10), the lymphatic drainage comprised three major routes: (1) the prostate to the lymph nodes along the lateral bony wall of the pelvis to the angle of internal/external iliac lymph nodes to the common iliac lymph nodes, (2) the prostate to the perineal floor to the pudenda internal lymph nodes to the angle of the internal/external iliac lymph nodes to the common iliac lymph nodes, and (3) the prostate to the sacral lymph nodes. In all 10 patients, main contrast medium enhancement was seen immediately after procedure indicating drainage from the prostate to the lymph nodes along the lateral bony wall of the pelvis. Presacral lymph node enhancement was seen in all patients only in the late (24 hours after contrast injection) radiograph.

CONCLUSIONS

Our data suggest that the main lymphatic drainage, irrespective of the prostatic region (transition or peripheral zone), runs to the pelvic regions that are mostly removed by standard lymphadenectomy techniques. However, one has to bear in mind that the prostate has some lymphatic drainage that is not covered by standard lymphadenectomy and therefore carries the risk of metastatic tumor spread.

Use of peripheral neuromodulation of the S3 region for treatment of detrusor overactivity: a urodynamic-based study

OBJECTIVES

To determine the efficacy of peripheral neuromodulation of the S3 region in patients with urgency-frequency syndrome due to an overactive bladder.

METHODS

Fifteen patients (11 women and 4 men) with urgency-frequency syndrome, as documented by a voiding chart, were diagnosed with overactive bladder. Pelvic pain was assessed by a visual analogue scale (VAS). Full urodynamic workup was performed before and after 12 peripheral stimulations with a 9-V monopolar generator, the so-called Stoller Afferent Nerve Stimulator (SANS). Follow-up was for a mean (SD) of 10.9 (4 to 15) months.

RESULTS

Reduction in pain was achieved in all patients, with a decrease in VAS from a mean (SD) of 7.6 (5 to 10) to 3.1 (1 to 7) (P = 0.00049). Seven patients (46.7%) had a complete response and were considered cured, 3 (20.0%) showed significant improvement, and 5 (33.3%) were classified as nonresponders. Urodynamic evidence of bladder instability, evident in all patients before treatment, was eliminated in 76.9% of patients. In all patients, mean (SD) total bladder capacity increased significantly from 197 (35 to 349) to 252 (78 to 384) mL (P = 0.00795), mean (SD) volume at first bladder sensation from 95 (16 to 174) to 133 (32 to 214) mL (P = 0.00166), and mean (SD) bladder volume at normal desire to void from 133 (27 to 217) to 188 (47 to 296) mL (P = 0.00232). In the responding group, the mean (SD) total numbers of voids was reduced from 16.1 (9 to 24) times during the day and 4.4 (2 to 6) times during the night to 8.3 (6 to 10) and 1.4 (1 to 2) times (P = 0.002539), respectively. No complications from treatment were observed.

CONCLUSIONS

Peripheral neuromodulation of the S3 region can successfully treat patients with urgency-frequency syndrome due to an overactive bladder.

A comparative study of a double-line versus a fan-shaped technique for obtaining transrectal ultrasound-guided biopsies of the prostate

INTRODUCTION AND OBJECTIVES

Transrectal ultrasound-guided biopsy of the prostate is an established method to obtain prostate specimens for histological analysis. The aim of this prospective study was to compare the prostate cancer detection rate of the conventional double-line biopsy to a more fan-shaped biopsy technique.

METHODS

A total of 107 men were included in this study. The indication for performing a prostate biopsy was a serum prostate-specific antigen level exceeding 4 ng/ml and/or suspicious findings on digital rectal examination. 53 patients were biopsied by the conventional double-line technique (method A): 3 biopsies in the midparasagittal plane from each lobe at the apex, middle and basis, at an angle of approximately 45 degrees C. 54 patients were biopsied with the so-called fan-shaped technique (method B): 6 biopsies were taken from the left to the right lateral margin in one plane at the same angle.

RESULTS

642 prostate biopsy cores were obtained, a subset of 133 biopsies were identified to yield prostate cancer. The percentage of positive biopsies was higher in group B (n = 81; 61%) as compared to group A (n = 52; 39%). The overall prostate cancer detection rate by the fan-shaped technique was 37% (20/54) as compared 30.1% (16/53) to the conventional double-line technique, but this difference did not reach statistical significance (p < 0.05) presumably because of the small number of patients.

CONCLUSION

These data suggest that the fan-shaped biopsy technique seems to have a higher cancer detection rate and a higher number of positive core biopsies than the conventional double-line technique, because of more presence in the apex and the peripheral zone of the prostate where most prostate cancers originate from.

Implantable microballoons: an attractive alternative in the management of intrinsic sphincter deficiency

PURPOSE

All current bulking agents employed for treating stress urinary incontinence (SUI) have significant limitations due to various side effects, technical difficulties and inadequate long-term results. Implantable microballoons were therefore tested as a new therapeutic modality for female urinary incontinence.

MATERIAL AND METHODS

The microballoons are implanted with a new system which consists of the self-detachable cross-linked silicone balloon, biocompatible filler material and a delivery system. Nineteen female patients (mean age 63.3 years) with SUI grade 1 or 2 were studied prospectively. Using the Blaivas-Olsson classification, 6 patients had stress incontinence type I, 4 had type II and 9 had type III. Three to seven balloons (mean 4.2) were implanted per patient. Patients were followed up with pad tests (g) and determination of leak point pressure (LPP; cm H2O) and maximal urethral closing pressure (Pura max; cm H2O) at 1, 3, 6, 12 and 18 months.

RESULTS

The biocompatibility of the microballoons was excellent. No significant adverse events were associated with the procedure. With a mean follow-up of 14.4 months (range 10-18) 42.1% (8/19) of the women are dry. In the latter the pad test improved from a preoperative mean of 22.6 g (2-75) to 0 and the LPP increased from a preoperative mean of 38.5 cm H2O (25-60) to 80.5 cm H2O (68-106). 36.8% (7/19) of the patients showed significant improvement of their incontinence. In this group the pad test improved from a preoperative mean of 39.1 g (8-112) to 9.7 g (2-29) and LPP from a mean of 37.1 cm H2O (25-50) to 42.0 cm H2O (30-58). In 4 patients (21.05%) the technique failed. Seven of the 8 cured patients had type III incontinence; the eighth patient had type I incontinence. It failed in all patients with type II incontinence.

CONCLUSION

The implantation of microballoons is a safe, well-tolerated and clinically effective modality for the treatment of type III SUI, i.e. intrinsic sphincter deficiency.

A 3,500-gram leiomyoma of the bladder: case report on a 3-year follow-up after surgical enucleation

We report on a unique-sized large leiomyoma of the bladder wall in a male patient. After open surgical intervention all symptoms resolved spontaneously and no relapse occurred within a 3-year follow-up period. In conclusion, for symptomatic leiomyoma of the bladder surgical intervention should be considered as an early treatment option since it is associated with low morbidity, a high cure rate for this type of tumor and an immediate relief of urological symptoms.

Comparison of two qualitative assays, the UBC rapid test and the BTA stat test, in the diagnosis of urothelial cell carcinoma of the bladder

OBJECTIVES

To compare the diagnostic value of two rapid tests, the bladder tumor antigen (BTA stat) test and the newly developed urinary bladder cancer (UBC) Rapid test, in patients having symptoms suggestive of urothelial cell carcinoma (UCC) and patients being followed up after transurethral resection.

METHODS

One hundred eighty patients with a mean age of 65.8 years (range 22 to 92) were included in the present study. The tests were performed on voided urine samples. Fifty-seven patients had symptoms suggestive of UCC and 123 patients were being followed up after complete transurethral resection of UCC. The voided urine was evaluated by the BTA stat and UBC Rapid test, which detects cytokeratins 8 and 18. All patients underwent subsequent cystoscopic evaluation and biopsy of any suspicious lesion.

RESULTS

In 53 patients with histologically proved UCC, the BTA stat had a sensitivity of 52.8% and the UBC Rapid test of 66%. According to the histologic stage, the sensitivity of the BTA stat was 42.8% in pTa tumors, 61.5% in pT1, and 70% in pT2 or higher tumors. The sensitivity of the UBC test was 60.7% in pTa, 69. 2% in pT1, and 80% in pT2 or higher tumors. For histologic grades 1 to 3, the sensitivity was 38.8%, 52.6%, and 68.7% for the BTA stat and 44.4%, 78.9%, and 75% for the UBC Rapid test, respectively. The specificity was 70% and 90% for the BTA stat and UBC Rapid test, respectively.

CONCLUSIONS

The UBC Rapid test was superior to the BTA stat in both sensitivity and specificity. Both assays are simple office procedures and require no special knowledge. However, they cannot replace, but only lower, the number of cystoscopies during the follow-up of patients with previous UCC of the bladder.

The International Prostate Symptom score in both sexes: a urodynamics-based comparison

The aim of our study was to determine the urodynamic basis for the observation that aging women report comparable benign prostatic hyperplasia (BPH) symptom scores as age-matched men. Sixty-seven women (mean age, 60.4 +/- 1.5 years; mean +/- standard error of the mean) and 70 age-matched men (mean age, 63.7 +/- 0.9 years; P > 0.05) entered this prospective study. Men were referred for the diagnostic workup of lower urinary tract symptoms (LUTS) due to BPH and women predominantly for urinary incontinence. All patients completed the International Prostate Symptom score (IPSS) with quality-of-life assessment and underwent a detailed clinical and urodynamic evaluation including a multichannel pressure-flow study. Results of the IPSS, quality-of-life assessment, and irritative and obstructive component of the IPSS were correlated with urodynamic findings and the respective data were compared in both sexes. The mean IPSS was 15.7 for men and 13.0 for women (P = 0.02), quality-of-life score was higher in women (4.2 vs. 3.4; P = 0.0008). The irritative score was significantly higher in women (8.7 vs. 6.8; P = 0.003). Incidence of detrusor instability (DI), however, was higher in men (women, 38.1%; men, 48.6%; P = 0.015) and bladder capacity was higher in women (425 vs. 333 ml; P = 0.0001). There was no correlation between incidence and degree of DI with the irritative score in both sexes. The obstructive score was significantly higher in men (8.8 vs. 4.4; P = 0.0001). Ninety-one percent (64/70) of men had urodynamically documented bladder outlet obstruction (BOO), whereas this was the case in only 9% (6/67) of women. In parallel to the irritative score, we could not identify a correlation between the degree of urodynamically proven BOO and the obstructive score in both sexes. This urodynamics-based comparison fails to give an explanation for the observation that aging women report similar BPH scores as men. These data suggest that other mechanisms, such as changes in diurnal urine production, structural alterations of the aging detrusor, endocrine disturbances affecting lower urinary tract function, and subtle urodynamic changes are responsible.

Interrelationships of bladder compliance with age, detrusor instability, and obstruction in elderly men with lower urinary tract symptoms

Data on the interrelationships of bladder compliance (BC), detrusor instability (DI), and bladder outflow obstruction (BOO) in elderly men with lower urinary tract symptoms (LUTS) are scarce and were therefore assessed in this study. Principle inclusion criteria for this study were men aged > or = 50 years suffering from LUTS as defined by an International Prostate Symptoms Score (IPSS) of > or = 7 and a peak flow rate (Qmax) of < or = 15 ml/sec. Patients with previous surgery of the bladder, prostate, or urethra as well as a pathological neurourological status were excluded from this study. The following parameters were studied in all patients: IPSS, prostate volume calculated by transrectal ultrasonography, free uroflow study, post-void residual volume determined by transurethral catheterization, and a multichannel pressure flow study (pQS). A group of 170 men were included in the analysis. The mean BC in the overall group was 32 +/- 2 ml/cm H2O (mean +/- standard error of the mean [SEM]; range, 4-100 ml/cm H2O). In 36.5% of patients, BC was significantly reduced (< or = 20 ml/cm H2O), and in a further 37.1%, it ranged from 20 to 40 ml/cm H2O. BC decreased statistically significantly (p < 0.05) in patients with advanced age, lower Qmax, higher voiding pressures, and larger prostates. In men with DI (n = 61), mean BC was significantly lower (22 +/- 3 ml/cm H2O) compared to those without (37 +/- 3 ml/cm H2O; p = 0.001; n = 109). Patients with severe BOO as defined by a linear passive urethral resistance relationship of > or = 3 (n = 109), had a significantly lower BC (23 +/- 2 ml/cm H2O) compared to those without or minimal obstruction only (39 +/- 3 ml/cm H2O; p = 0.0002; n = 61). Stepwise logistic regression analysis revealed that DI, a low bladder capacity, and a high maximum detrusor pressure were independent predictors of markedly reduced BC (< 20 ml/cm H2O). BC is decreased in elderly men with high voiding pressures, BOO, and DI. The mechanism leading to the reduction of BC under these circumstances is largely unknown and could result from cytostructural alterations of the detrusor and changes in detrusor innervation.

Serum dehydroepiandrosterone sulfate concentrations in men with erectile dysfunction

OBJECTIVES

In 1994, the Massachusetts Male Aging Study presented the finding of an inverse correlation of the serum levels of dehydroepiandrosterone sulfate (DHEAS) and the incidence of erectile dysfunction (ED). Prompted by the positive results of a pilot study on the treatment of ED with dehydroepiandrosterone (DHEA), we performed a detailed investigation on the serum DHEAS levels in men with ED according to age category.

METHODS

Inclusion criteria included a history of ED for more than 6 months, a body mass index less than 30, and a state of good general health. Serum DHEAS concentrations were determined in 309 patients with ED and 133 healthy volunteers. All participants were carefully screened to assess medical factors known or suspected to alter endocrine function. Questions 3 and 4 of the International Index of Erectile Function were used to evaluate erectile function.

RESULTS

The mean serum levels of DHEAS in patients with ED were lower than in healthy volunteers until 60 years of age. The shape of the curve of the patients with ED indicated a quadratic decrease of DHEAS with age in contrast to a more linear decrease of DHEAS with age in the control group.

CONCLUSIONS

Our results suggest that until the age of 60 years, the mean serum level of DHEAS is lower in patients with ED than in healthy volunteers.

[Placebo-controlled dihydroepiandrosterone substitution in elderly men]

We evaluated the efficacy of dehydroepiandrosterone substitution in elderly men with erectile dysfunction. Fifty patients were randomly divided into two groups of 25 patients each. Group 1 was treated with a single oral dose of dehydroepiandrosterone (50 mg/day), whereas group 2 patients received a placebo. The International Index of Erectile Function was used to rate the success of this therapy. The patients in group 1 had a statistically significant increase in all domains of this index, in contrast to group 2 patients. Although our patient data are too small to perform a relevant statistical analysis, we believe that they represent a biologically obvious trend that justifies further extended studies.

Twelve prostate biopsies detect significant cancer volumes (> 0.5 mL)

OBJECTIVES

To compare, in a retrospective study, pathological specimens of prostate cancer detected in additional areas of a 12-core biopsy with tumours detected using traditional sextant biopsy.

PATIENTS AND METHODS

The study included 27 patients who had undergone radical prostatectomy (RP) for prostate cancer. Prostatectomy specimens of cancers detected using standard sextant biopsies were compared with those detected using six additional core biopsies. The RP specimens were analysed for cancer volume, Gleason score, tumour grade (Mostofi) and pathological stage.

RESULTS

Of the 27 patients, six (29%) had cancer detected in the extra six biopsy cores which would have otherwise have been undetected using sextant biopsy. Only two insignificant cancers were detected. The mean Gleason score was 6.1 for cancer detected by the sextant or 12-core method (P = 0.907); the mean grade (Mostofi) was 2.1 and 2. 33, respectively (P = 0.29). The final tumour stage in the 21 patients undergoing sextant biopsy was pT2 in 13 and pT3 in eight, compared with six pT2 tumours in the six patients diagnosed using extra biopsies. The mean (median, range) tumour volume was 5.7 (3.5, 0.312-23.75) mL for cancers detected on sextant biopsy and 1.99 (1. 85, 0.4-3.6) mL in the six cancers detected using extra cores (P = 0. 0138).

CONCLUSION

The detection of prostate cancer was increased using extra biopsy cores. There was a significant difference in tumour volume but not in Gleason score, Mostofi grade or final pathological tumour stage between tumours diagnosed using 12 cores and those detected on sextant biopsy.

Comparison of the monoclonal UBC-ELISA test and the NMP22 ELISA test for the detection of urothelial cell carcinoma of the bladder

OBJECTIVES

To compare the diagnostic value of two enzyme-linked immunosorbent assay (ELISA) tests, the nuclear matrix protein 22 (NMP22) test and a newly developed urinary bladder cancer (UBC) test, in patients having symptoms suggestive of urothelial cell carcinoma (UCC) and patients under follow-up after transurethral resection (TUR).

METHODS

Two hundred forty patients with a mean age of 65.8 years (range 22 to 92) were included in this retrospective study. The tests were performed on previously frozen urine samples. Eighty-one patients had symptoms suggestive of bladder cancer and 159 patients were being followed up after complete TUR of UCC. Voided urine was evaluated by the NMP22 test and the monoclonal UBC-ELISA test, which traces cytokeratins 8 and 18. All patients underwent subsequent cystoscopy and biopsy evaluation of any suspicious lesion. The cutoff levels for bladder cancer positivity were 10 U/mL for the NMP22 test and 12 microg/L for the UBC test.

RESULTS

In the 54 patients with histologically proved UCC, the NMP22 test had a sensitivity of 55.5% and the UBC test a sensitivity of 64.8%. According to the histologic stages, the sensitivity of NMP22 was 51.7% in pTa tumors, 46.1% in pT1, and 70% in pT2 or higher tumors; the sensitivity of UBC was 62.1% in pTa, 53.8% in pT1, and 80% in pT2 or higher tumors. For histologic grades 1 to 3, the sensitivity was 50%, 50%, and 68.7% for NMP22 and 66.6%, 60%, and 68.7% for UBC, respectively. The specificity was 79% and 92% for NMP22 and UBC, respectively.

CONCLUSIONS

The monoclonal UBC-ELISA test is superior to the NMP22 test in both sensitivity and specificity. Nevertheless, neither test can replace cystoscopy.

Comparative study of two different TRUS-guided sextant biopsy techniques in detecting prostate cancer in one biopsy session

OBJECTIVE

The aim of this study was to compare a transrectal ultrasound (TRUS)-guided sextant biopsy technique, which puts more emphasis on the apical region of the prostate where most prostate carcinomas (PCs) develop, with the standard sextant biopsy technique.

METHODS

A total of 280 patients with suspected PC were included in this analysis. Twelve biopsy cores were obtained from all patients. Six biopsy cores were taken within a lateral parasagittal plane from each lobe at the apex, middle and basis, with an angle of approximately 45 degrees (technique A), and 6 further biopsy cores were taken from the left to the right lateral margin always penetrating the prostate in the apex with the same angle (socalled fan-shaped technique, technique B). Technique A predominantly samples in the sagittal and technique B samples more in the transversal plane with emphasis on the apical region where most PCs develop. The sensitivity in detecting PCs for both techniques was calculated and correlated to the serum prostate-specific antigen (PSA) levels.

RESULTS

A total of 72 PCs (25.7%) were diagnosed. We subsequently performed subgroup analysis depending on the serum PSA levels: in patients with a PSA of </=10 ng/ml (n = 27) technique A has a PC sensitivity of 88.8% (p = 0.037) and technique B 96.2% (p = 0.326) as compared to our reference standard of 100% by sampling 12 biopsy cores in the same prostate. The number of positive biopsy cores using technique B was superior in 12 cases as compared to 3 cases with technique A (p = 0.04). In 12 patients the number of positive biopsy cores was identically. In patients with a PSA of >10 ng/ml (n = 45) technique A has a PC sensitivity of 93.3% (p = 0.083) and technique B 88.8% (p = 0.023) as compared to our reference standard. The number of positive core biopsies using technique A was superior in 14 cases as compared to 12 with technique B (p = 0.154). In 19 patients the number of positive biopsies was identical.

CONCLUSION

Our data suggest that in patients with PSA of </=10 ng/ml technique B bring significant benefit with regard to the number of positive core biopsies, as well as an enhanced PC detection rate which is near the 12-core biopsy. Due to the fact that technique B samples more in the apical region where most cancers develop, it should be performed in suspected early stage cancers of the prostate (PSA</=10 ng/ml).

Value of power Doppler sonography in the investigation of erectile dysfunction

OBJECTIVES

The poor sensitivity of conventional color-coded Doppler sonography (CCD) for low-flow signals limits its use for investigating patients with erectile dysfunction. Power Doppler sonography (PD) has recently been described for enhanced visualization of the microcirculation. Aim of this study was to determine the value of PD to demonstrate penile vascular pathophysiology as compared with conventional techniques.

METHODS

33 consecutive men with erectile dysfunction were investigated using the standard workup with conventional CCD and cavernosography before and after prostaglandin E(1) intracavernosal injection. Patients were subdivided into an arteriogenic, a venogenic, or a psychogenic group according to findings in the standard diagnostic workup. PD was used in addition to the standard protocol to demonstrate microcirculation, arterial blood flow, and venous leakage. The accuracy of the diagnosis obtained by PD and response to intracavernosal injection was compared with the clinical outcome in these groups at 6 months.

RESULTS

PD was found to be superior to CCD in visualizing cavernosal microcirculation. In addition, arterial flow at basal peak systolic velocity was demonstrated in all patients with PD, whereas a signal sufficient for evaluation was obtained with CCD in only 69.7% (23/ 33). No significant difference in the maximal peak systolic velocity was noted using either PD or CCD. The positive predictive value of PD for venous leakage was poor (60%) when compared with cavernosography. PD used in conjunction with the response to intracavernosal injection was found to reliably predict the clinical outcome in the arteriogenic (p = 0.0007), the venogenic (p = 0.005), and the psychogenic group (p = 0.0002).

CONCLUSIONS

Our data indicate that PD improves the evaluation of penile microcirculation and arterial function, but fails to reliably demonstrate venous leakage alone. Nevertheless, in most patients cavernosography could have been avoided by the aid of PD, since the underlying pathology can be calculated at a high predictive value without the need of further invasive tests. Therefore, with the aid of PD, the morbidity for patients being investigated for erectile dysfunction can be significantly reduced.

The impact of urinary extravasation after radical retropubic prostatectomy on urinary incontinence and anastomotic strictures

OBJECTIVE

The aim of this study was to determine the relevance of urinary extravasation as proven by cystogram 18 days after radical retropubic prostatectomy for the degree of postoperative urinary incontinence and the incidence of anastomotic strictures.

PATIENTS AND METHODS

A total of 225 patients underwent radical retropubic prostatectomy at our institution during a 30-month period, 215 of whom received a cystogram a mean 18 days following surgery. Three and 6 months after surgery these 215 patients were evaluated regarding the degree of urinary incontinence and the presence of anastomotic strictures.

RESULTS

The cystogram demonstrated a watertight anastomosis in 89% (n = 195; group I), the remaining 11% (n = 24; group II) showed urine extravasation. Groups I and II were comparable with respect to age, preoperative serum levels of prostate-specific antigen (PSA), tumor grade and pathological staging. Six months after surgery, there was no statistically significant (p > 0.05) difference between both groups regarding the degree of urinary incontinence and the presence of anastomotic strictures.

CONCLUSIONS

The presence of urine extravasation 18 days after radical retropubic prostatectomy has no impact on postoperative urinary incontinence and the incidence of anastomotic strictures. Based on these data it is not indicated to leave the catheter in situ beyond that point of time.