The HELENA study: Hexvix®-TURB vs. white-light TURB followed by intravesical adjuvant chemotherapy-a prospective randomized controlled open-label multicenter non-inferiority study

Purpose

Photodynamic diagnosis and white-light TURB with adjuvant intravesical chemotherapy (ICT) is widely used in treatment of bladder cancer. This non-inferiority trial is designed to demonstrate non-inferiority regarding recurrence-free survival (RFS) of Hexvix^® TURB followed by immediate instillation compared to white-light TURB with immediate instillation followed by maintenance ICT.

Methods

Between 07/2010 and 12/2016, 129 patients with EORTC intermediate risk non-muscle invasive bladder cancer treated with TURB were included in this multicentre phase III study. Patients were randomized and received either white-light TURB with immediate ICT followed by maintenance ICT (n = 62, 20 mg Mitomycin weekly for 6 weeks as induction phase, afterwards 20 mg/month for 6 months) or Hexvix^® TURB with immediate ICT only (n = 67, 40 mg Mitomycin). Primary study endpoint was RFS after 12 months. Hexvix^® TURB was counted as non-inferior to white light alone if the upper limit of the one-sided 95% confidence interval of hazard ratio was lower than 1.676. Due to the non-inferiority design, the per-protocol population was used as the primary analysis population (n = 113)

Results

Median follow-up was 1.81 years. Hexvix^® group showed more events (recurrence or death) than white-light group (19 vs. 10) resulting in a HR of 1.29 (upper limit of one-sided 95%-CI = 2.45; p_{non-inferiority} = 0.249). The ITT population yielded similar results (HR = 1.67); 3.18], p_{non-inferiority} = 0.493). There was no significant difference in overall survival between both groups (p = 0.257).

Conclusion

Non-inferiority of Hexvix^® TURB relative to white-light TURB with maintenance Mitomycin instillation in intermediate risk urothelial carcinoma of the bladder was not proven. Hence a higher effect of maintenance ICT is to assume compared to a Hexvix^®-improved TURB only, confirming its important role in patient treatment.

Minimizing complications during retropubic radical prostatectomy - Is ureteral stenting necessary?

OBJECTIVES AND AIMS

To avoid damage to the ureters during bladder neck preparation in radical prostatectomy for prostate cancer, it may be helpful to insert ureteral stents temporarily or to intravenously administer indigo carmine dye for enhanced visualisation of ureteric orifices. We evaluated our bladder neck preserving technique at radical prostatectomy with regard to ureteric injuries.

PATIENTS AND METHODS

We analysed 369 consecutive radical prostatectomies operated in our clinic in a bladder neck preserving technique. The following parameters were assessed in this retrospective study: number of prophylactic ureteric stent insertions, application of indigo carmine dye, observed injuries of the ureters by the surgeon, postoperative increase of serum creatinine and postoperative status of kidney ultrasound.

RESULTS

In 7/369 prostatectomies (1.90%) a ureteric stent insertion was performed, indigo carmine was not applied to any patient at all, yet no intraoperative injury of a ureter was observed by a surgeon. No revision was necessary due to a ureteral injury within the observation period of one year after surgery. In 17 patients with preoperative normal creatinine value a pathological value was observed on the first postoperative day (mean 1.4 mg/dl). In these patients no consecutive postrenal acute renal failure was observed, no hydronephrosis was monitored by ultrasound and no further intervention was necessary.

CONCLUSIONS

Bladder neck preserving operation technique does not implicate the need of prophylactic ureteric stent insertions and has no higher incidence of ureteric injuries.

[Fluorescence cytology. Improvement of urinary cytology]

Urothelial cancer of the bladder is a frequent disease, and urinary cytology often is used as a routine diagnostic tool. But this technique has an impaired sensitivity in low-grade tumours, and as a subjective method it is highly dependent on the experience of the cytologist. Here we present the technique of fluorescence cytology as an improvement of conventional cytology. This method is potentially able to compensate for the disadvantages of urinary cytology as it is an automated process that uses the principles of 5-Ala-induced photodynamic diagnosis (PDD).

[Urine cytology and urine markers. Significance for clinical practice]

Urothelial carcinoma of the bladder is a frequent disease that can be identified timely by screening patients at high risk. Due to the high rate of disease recurrence, frequent follow-up procedures are necessary. For this purpose, cystoscopy is the standard procedure, and supplementary non-invasive procedures such as cytology or tumor marker tests are used. These tests have different advantages and disadvantages in terms of their sensitivities and specificities. Thus, they provide additional information, but are not able to replace cystoscopy as the standard instrument in the diagnosis of bladder cancer.

[Urinary cytology. Possibilities, limitations and the future]

Even now, 60 years after the fundamental studies on oncological urinary cytology carried out by Papanicolaou and Marschall and the subsequent integration of the test they devised into the diagnostic investigations applied in the diagnosis of urothelial carcinoma, urinary cytology still maintains its place in the diagnosis of primary and recurrent tumours of the urinary tract. Newer diagnostic techniques involving urine-bound tumour markers have not so far achieved such high levels of acceptance as their method. It is possible, certainly, that a combination of these newer methods with cytological testing, or with other innovative diagnostic methods, such as photodynamic techniques, could prove very promising in the future and might overcome the limitations of urinary cytology.

Nichtinvasives und invasives Harnblasenkarzinom

Therapy of superficial bladder tumors is transurethral resection (TUR), and in cases of pT1 or high-grade tumors a re-TUR is indicated. Patients with carcinoma in situ receive intravesical chemotherapy or BCG for at least 3 months. Persistent carcinoma in situ may be treated by radical cystectomy. With the provision of a functionally adequate urinary diversion, cystectomy represents an effective treatment for patients with muscle-invasive bladder cancer without metastatic spread. Regional lymph node metastases can be found in up to 15% of stage T1 disease and are present in 33% of stage T3/4 lesions. Thus, lymphadenectomy gains diagnostic and possibly also therapeutic importance. For selected patients, who cannot be treated by radical cystectomy, multimodal concepts aiming to preserve the bladder are discussed. After or prior to cystectomy systemic chemotherapy may become necessary for some patients to positively affect the course of the disease in cases of locally advanced or metastatic lesions.

[Painless enlargement of the scrotum]

Painless swelling of the scrotum may be due either to an increase in bulk of the scrotal contents or to changes affecting the skin of the scrotum. The reliable and rapid differentiation of harmless from serious conditions such as cancer of the testicles, is essential.

Harnblasentumoren

Increasing knowledge in molecular genetic research on urinary bladder carcinoma has allowed us to classify the morphological picture on the basis of a better understanding. But this new knowledge will only be ground-breaking if it can be correlated with the clinical outcome of urinary bladder tumours and with histopathological findings. The use of the new 2004 WHO classification results in a standardized diagnosis of urothelial tumours by means of an exact definition of the subgroups. In the future, trials can thus be compared worldwide and risk profiles can be stratified. Further research in molecular genetics and correlation with the current classification together with molecular biological techniques may allow refinement of this scheme, e.g. by immunohistochemical subclassifications, enabling identification of potentially genetically unstable tumours. In this paper we present the new 2004 WHO classification of urinary bladder tumours emphasizing the changes in relation to the former classifications focusing on histological typing, grading and molecular characterization. Until the new classification is finally validated, and those working in the field have become familiar with it, the WHO classification of 1973 should be mentioned additionally in the histopathological report.

Fluorescence diagnosis: a novel method to guide radical inguinal lymph node dissection in penile cancer

In penile cancer there is still a diagnostic dilemma between over treatment of lymph node-negative patients and the missing of occult metastases by watchful waiting. In the current study the value of fluorescence diagnosis during radical inguinal lymph node dissection was evaluated. Five patients with penile cancer were elected to undergo groin dissection. All patients received 5-aminolevulinic acid (5-ALA) orally before the operation for fluorescence diagnosis. Intraoperatively, fluorescence detection of the lymph nodes was performed by visual detection and spectroscopy. Two of the five patients had positive inguinal lymph nodes. Fluorescence in tumor-bearing tissue was detectable in the exposed lymph nodes. Protoporphyrin IX (PPIX) is accumulated in tumor-positive lymph nodes, making fluorescence diagnosis in penile cancer possible. More studies with higher patient numbers are necessary to evaluate optimal dosage and excitation conditions to detect tumor-bearing nodes in vivo.

[Precancerous conditions in the urothelium. Early detection and molecular understanding through endoscopic fluorescence diagnosis]

Fluorescence diagnosis after application of 5-aminolevulinic acid (ALA) detects red-fluorescing preneoplastic and neoplastic lesions using light excitation. The principle of the method is the relative tumor-selective accumulation of the metabolite protoporphyrin IX (PPIX), which is built intracellularly out of exogenously applied ALA. The early detection of tumors and especially preneoplasias is an ideal prerequisite for genetic analysis of these lesions. With this approach, methods such as fluorescence in situ hybridization and loss of heterozygosity analysis for deletion mapping as well as gene sequencing data could be compared. New data are presented on deletions, numeric chromosomal aberrations, and oligoclonality of tumors found in about 30% of cases. The phenomenon of tumor-selective fluorescence was further investigated by parallel biochemical analysis, which showed marked differences in heme metabolism. The analysis of gene and protein expression may aid in identifying tumor-specific molecules associated with heme metabolism.

Ex-vivo comparison of the haemostatic properties of standard transurethral resection and transurethral vaporization resection of the prostate

OBJECTIVE

To compare the haemostatic properties of standard transurethral resection of the prostate (TURP) and transurethral vaporization resection of the prostate (TUVRP), as perioperative bleeding is still regarded as the major complication of prostate resection.

MATERIALS AND METHODS

Isolated blood-perfused porcine kidneys were used to determine the haemostatic efficacy of TURP and TUVRP (using two different electrodes). Bleeding was quantified precisely in relation to tissue ablation for the two techniques, and specimens were evaluated histologically.

RESULTS

Both TUVRP groups had significantly less bleeding (P = 0.005) than the TURP group for a standardized ablation volume of perfused kidney tissue (18.9, 19.5 and 24.1 mL/min, respectively). The different TUVRP electrodes had no significant haemostatic differences. The histology showed significantly (P = 0.03) larger coagulation zones for the TUVRP groups than for standard TURP.

CONCLUSIONS

TUVRP ex-vivo was associated with significantly better haemostasis than TURP. The haemostatic properties of different active electrodes for TUVRP seem to be equivalent.

[Urological emergencies]

Urological emergencies that require specialist treatment include testicular torsion, gross hematuria, urogenital injuries and acute flank pain. After initial symptoms-adapted therapy, patients should be transferred immediately to an urological department for imaging (e.g. ultrasound, IVP, CT) and further specific examinations (e.g.blood tests, urine analysis, microbiology). Acute lower abdominal and scrotal pain in young men may be symptomatic of testicular torsion, which requires immediate urological surgery. Gross hematuria is usually not a life-threatening emergency. Nevertheless, urogenital tumor has to be ruled out by an urologist. Patients with urogenital injuries are triaged into surgical and non-surgical treatments. Differential diagnosis of acute flank pain falls into several medical fields. After initial symptom-related therapy, further diagnostic procedures have to be performed. Septic presentation may be symptomatic of infectious hydronephrosis which requires immediate urological intervention.

Recurrence of condylomata acuminata of the urethra after conventional and fluorescence-controlled Nd:YAG laser treatment

OBJECTIVES

To report our experience with conventional and fluorescence-controlled neodymium:yttrium-aluminum-garnet (Nd:YAG) laser therapy of urethral condylomata. Urethral condylomata can sometimes only be reached by endoscopy and are in general very susceptible to recurrence. They must therefore be considered as a therapeutic problem that has not yet been resolved.

METHODS

One hundred sixty-eight patients with urethral condylomata were treated with the Nd:YAG laser (93 men using conventional white-light endoscopy and 75 men using fluorescence control after topical application of 5-aminolevulinic acid). The relapse characteristics were investigated according to the location and extent of the urethral lesions and with regard to the different endoscopy techniques.

RESULTS

Of all patients, 35.7% developed recurrences of urethral condylomata after laser therapy. These were mainly located on the meatus and in the distal urethra. Only 4.8% of patients had proximal condylomata, and this was only seen in people with distal urethral involvement. Extensive, complete, or semicircularly arranged condylomata developed recurrence and complications (eg, strictures) more frequently after laser therapy. Significantly fewer recurrences (21.3% versus 47.3%) were observed in fluorescence-controlled laser therapy in a retrospective comparison with laser therapy under conventional conditions with a corresponding extent of human papillomavirus lesions.

CONCLUSIONS

Nd:YAG laser therapy enables a specific topical clearance of human papillomavirus lesions at different locations in the urethra. 5-Aminolevulinic acid-induced fluorescence diagnostics enhances the effectiveness of Nd:YAG laser therapy of human papillomavirus lesions. Urethral instrumentation of any kind leads to viral contamination of the proximal urethra.

[Your patient with carcinoma of the urinary bladder. Options for organ preservation]

Every year, some 18,000 persons develop cancer of the bladder, making it one of the most common of the malignant diseases. Major underlying causal factors are exposure to aromatic amines, nicotine abuse, chronic infections and various medications. On the basis of the TMN system, a differentiation is made between superficial, invasive and metastasizing (lymphogeneous, hematogenous) carcinomas. A classical symptom is painless hematuria. The diagnosis is established primarily by white-light cystoscopy. Superficial urothelial lesions, which are often overlooked with this method, may be detected with the aid of the more sensitive method of fluorescence endoscopy. Depending upon local tumor spread and degree of differentiation, treatment includes transurethral electrocoagulation, laser coagulation, instillation of cytostatics and immunotherapeutic agents, as well as--in the case of muscle invasion--radical cystectomy.

Frequent genetic alterations in flat urothelial hyperplasias and concomitant papillary bladder cancer as detected by CGH, LOH, and FISH analyses

Flat urothelial hyperplasia, defined as markedly thickened urothelium without cytological atypia, is regarded in the new WHO classification as a urothelial lesion without malignant potential. Frequent deletions of chromosome 9 detected by fluorescence in situ hybridization (FISH) have been previously reported in flat urothelial hyperplasias found in patients with papillary bladder cancer. Using comparative genomic hybridization (CGH) and microsatellite analysis, these hyperplasias and concomitant papillary tumours of the same patients were screened for other genetic alterations to validate and extend the previous findings. Eleven flat hyperplasias detected by 5-ALA-induced fluorescence endoscopy and ten papillary urothelial carcinomas (pTaG1-G2) from ten patients were investigated. After microdissection, the DNA of the lesions was pre-amplified using whole genome amplification (I-PEP-PCR). Loss of heterozygosity (LOH) analyses were performed with five microsatellite markers at chromosomes 9p, 9q, and 17p. CGH was performed using standard protocols. In 6 of 11 hyperplasias and 7 of 10 papillary tumours, deletions at chromosome 9 were simultaneously shown by FISH, LOH, and CGH analyses. There was a good correlation between FISH, LOH, and CGH analyses, with identical results in 6 of 10 patients. In addition to deletions at chromosome 9, further genetic alterations were detected by CGH in 9 of 10 investigated hyperplasias, including changes frequently found in invasive papillary bladder cancer (loss of chromosomes 2q, 4, 8p, and 11p; gain of chromosome 17; and amplification at 11q12q13). There was considerable genetic heterogeneity between hyperplasias and papillary tumours, but a clonal relationship was suggested by LOH and/or CGH analyses in 5 of 10 cases. These data support the hypothesis that flat urothelial hyperplasias can display many genetic alterations commonly found in bladder cancer and could therefore be an early neoplastic lesion in the multistep development of invasive urothelial carcinoma.

Penile carcinoma. Is Nd:YAG laser therapy radical enough?

PURPOSE

Penile carcinoma is a difficult disease to treat due to its aggressive nature and the psychological effects of amputation, which is often the recommended therapy. Outcome data from the last 13 years on patients with penile carcinoma treated with Nd:YAG laser coagulation were evaluated and compared with outcome data on conventional organ sparing techniques.

MATERIALS AND METHODS

For the last 13 years 29 patients were treated with Nd:YAG laser coagulation, including 17 with carcinoma in situ, and 10 with stage T1 and 2 with T2 cancer. Mean patient age was 55.1 years and mean followup was 46.7 months.

RESULTS

All patients are alive. Disease recurred in 1 patient with T1 tumor and 1 with carcinoma in situ. All patients were satisfied with the cosmetic and functional result.

CONCLUSIONS

Recurrence rates after Nd:YAG laser treatment for T1 tumors are comparable to those after partial amputation. Excellent cosmetic and functional results can be achieved without compromising oncological principles. For patients with metastasis prognosis is limited by the distant disease and, therefore, amputation is only necessary to achieve local control.

Penile carcinoma. Is Nd:YAG laser therapy radical enough?

PURPOSE

Penile carcinoma is a difficult disease to treat due to its aggressive nature and the psychological effects of amputation, which is often the recommended therapy. Outcome data from the last 13 years on patients with penile carcinoma treated with Nd:YAG laser coagulation were evaluated and compared with outcome data on conventional organ sparing techniques.

MATERIALS AND METHODS

For the last 13 years 29 patients were treated with Nd:YAG laser coagulation, including 17 with carcinoma in situ, and 10 with stage T1 and 2 with T2 cancer. Mean patient age was 55.1 years and mean followup was 46.7 months.

RESULTS

All patients are alive. Disease recurred in 1 patient with T1 tumor and 1 with carcinoma in situ. All patients were satisfied with the cosmetic and functional result.

CONCLUSIONS

Recurrence rates after Nd:YAG laser treatment for T1 tumors are comparable to those after partial amputation. Excellent cosmetic and functional results can be achieved without compromising oncological principles. For patients with metastasis prognosis is limited by the distant disease and, therefore, amputation is only necessary to achieve local control.

[Ambulatory radiosurgery in cerebral metastatic renal cell carcinoma. 5-year outcome in 58 patients]

Brain metastases (BM) indicate an advanced stage of renal cell cancer (RCC). They pose an increasing challenge to urologists as a result of improved survival due to modern therapy. Median survival of untreated patients with BM who often suffer from neurological deficits is 3 months. Radiosurgery with the Gamma Knife (GK) has increased in use as an alternative to whole brain radiation therapy (WBRT) and/or surgery. This study reports the results of a consecutive series of RCC patients treated for BM by GK radiosurgery during a 5-year period. Between 1994 and 1999, 58 patients with a total of 277 BM and 3.0 (1-19) BM/patient were treated. Because of recurrent BM, 23 (40%) patients received repeated (multiple) GK sessions. The median tumor volume was 3.4 cm3 (0.1-19.1). The median interval between diagnosis of RCC and GK treatment was 2.2 years (0.1-17.2). Symptomatic side effects were detected in 9 (16%) of 58 patients. The median actuarial survival time was 9.9 months. Local tumor control could be achieved in 95% of patients. The GK therapy induced a significant tumor remission accompanied by rapid neurological improvement in 70% of patients. Compared to standard radiotherapy, GK radiosurgery is more effective, less time consuming, and can be repeated. Compared to surgery, radiosurgery is less invasive and better suited to treat multiple metastases in one single session. Surgery and radiosurgery, however, are supplementary methods that are highly effective to control intracerebral metastasizing RCC.

[Telerobotic surgery between Baltimore and Munich]

The rapid development of laparoscopy in urology necessitates the training of specialists to guarantee the high standard of patient care. The real-time data communication of medical information between physicians in different locations is known as telemedicine. Telementoring describes the assistance of an experienced surgeon, while telerobotics requires the use of robots. Two robots, the established AESOP and the PAKY + RCM developed at the Johns Hopkins Hospital (JHH), were used to perform a telerobotic laparoscopic renal cyst ablation in cooperation between Baltimore and Munich. The telementor maneuvered the robots over a distance of 8000 km using eight ISDN lines and a PC. AESOP moved the camera, while PAKY allowed the use of a fan retractor in the abdomen. The telerobotic operation was performed without complications or system and communication failures. Telementoring can be used for training purposes but also for consultation between specialists in emergency settings.

[Fluorescent endoscopy superior to white light endoscopy. Detecting cancers of the urinary bladder earlier]

5-aminolevulinic acid-induced fluorescence endoscopy (AFE) has enormously increased the effectiveness of early cancer detection. This was first shown for cancer of the bladder. After application of 5-aminolevulinic acid (5-ALA) endogenous protoporphyrin IX (PP IX) accumulates in tumor tissue. When such tissue is then irradiated with blue light, the neoplastic areas can be identified by red fluorescence and, in the case of the bladder, can be removed by transurethral resection (TUR) or laser coagulation in the same endoscopic session. The great advantage of this highly sensitive technique (95%) is to be seen in particular in the detection of flat urothelial neoplastic lesions--until recently a deficit in conventional white-light endoscopy. Initial investigations show that improved early detection and the reduction in the residual tumor rate lead to longer recurrence-free intervals.

Use of hydro-jet cutting for laparoscopic partial nephrectomy in a porcine model

OBJECTIVES

To evaluate whether a laparoscopic hydro-jet device can provide a safe and effective partial nephrectomy. Partial nephrectomy is still one of the most challenging operations in urologic laparoscopy. The control of hemorrhage is very difficult to achieve with laparoscopic techniques. In open surgery, hydro-jet resection is used to cut the renal parenchyma selectively, avoiding damage to the vascular structures or collecting system.Methods. Laparoscopic wedge, as well as pole, resections of the kidney were performed in 5 pigs under general anesthesia. After exposure of the kidney, the renal capsule was incised using electrocautery. The hydro-jet was then used to dissect the renal parenchyma. In pole resections, the collecting system and central vessels were divided using an Endo-GIA. Hemostasis was achieved by electrocoagulation or clips. The dissection time and intraoperative complications were evaluated.Results. The operations were performed successfully in all animals without temporary ischemia. The hydro-jet generator allowed precise and effective tissue dissection without significant hemorrhage. The parenchymal vessels were selectively coagulated. The collecting system and central vessels remained intact and could be divided after application of the Endo-GIA. The mean dissection time was 42 +/- 6 minutes for the wedge resections and 54 +/- 8 minutes for the pole resections.

CONCLUSIONS

These experimental results demonstrate the suitability of hydro-jet dissection for safe laparoscopic partial nephrectomy without temporary ischemia and with reduction of the operative trauma to the kidney. On the basis of our own experiences with other techniques, including electrocautery and laser technology for partial nephrectomy, we conclude that laparoscopic hydro-jet resection represents an interesting alternative to other techniques.

Quantification of 5-aminolevulinic acid induced fluorescence improves the specificity of bladder cancer detection

PURPOSE

5-Aminolevulinic acid induced fluorescence endoscopy has outstanding sensitivity for detecting early stage bladder cancer. Nevertheless, a third of the lesions that show specific fluorescence are histologically benign. We decreased the false-positive rate of 5-aminolevulinic acid induced fluorescence endoscopy by incorporating protoporphyrin IX fluorescence quantification into the standard cystoscopy procedure.

MATERIALS AND METHODS

In 25 cases (53 biopsies) of a history of or suspicion for bladder cancer 5-aminolevulinic acid induced fluorescence endoscopy and fluorescence image quantification were performed. For fluorescence image quantification images obtained with a target integrating color charge-coupled device camera were digitized and stored in a personal computer. Red-to-blue ratios were calculated from fluorescence positive lesions and results were correlated with hematoxylin and eosin histology.

RESULTS

Malignant fluorescence positive lesions showed significantly stronger fluorescence intensity than fluorescing lesions with benign histology. A threshold was established that decreased the false-positive rate by 30% without affecting sensitivity.

CONCLUSIONS

Fluorescence image quantification is a new endoscopic method for objectively selecting multicolor fluorescence bladder lesion images for biopsy. It has the potential of eliminating human error by different surgeons with variable experience in fluorescence endoscopy.

Autofluorescence imaging to optimize 5-ALA-induced fluorescence endoscopy of bladder carcinoma

OBJECTIVES

To design an optical system for detecting autofluorescence (AF) of bladder tumors and to determine the success of reducing the false-positive rate of 5-aminolevulinic acid-induced fluorescence endoscopy (AFE). AFE provides significantly higher sensitivity in detecting and localizing bladder carcinoma compared with white light endoscopy. The specificity of AFE is equivalent to white light endoscopy, mostly because of the false-positive fluorescence of chronic cystitis lesions. Laser-induced spectral autofluorescence detection is also an efficient method in the diagnosis of bladder carcinoma.

METHODS

Bladder tissue was excited to AF using the D-Light (375 to 440 nm) after regular AFE with detection of fluorescence-positive areas. The optical image was produced using a special RGB camera. Biopsies were taken from AFE-positive areas, the peritumoral edges, and normal bladder mucosa. The AF images of the suspicious areas were compared with the AFE images and the histologic results.

RESULTS

A total of 43 biopsies were histologically examined (24 benign and 19 neoplastic). AF imaging showed contrast differences between papillary tumors, flat lesions, and normal mucosa. The combination of AFE with AF raised the specificity of AFE alone from 67% to 88%.

CONCLUSIONS

AF imaging is possible. The value of the method in reducing the false-positive rate of the highly sensitive AFE needs to be validated with higher numbers. The combination of AF with AFE had a 20% higher specificity than AFE alone in our study.

Simultaneous microsurgical spermatic vein ligation and sclerotherapy. a combined procedure for the treatment of recurrent or persistent varicocele

OBJECTIVES

Microsurgical ligation as well as antegrade sclerotherapy have been established in varicocele treatment. The aim of this study was to evaluate whether a combination of microsurgery and sclerotherapy can provide a safe and effective treatment of varicocele recurrence or persistence.

METHODS

Nine patients with recurrent or persistent varicoceles were operated by means of the combination method. Under microscopic control varix veins were ligated selectively preserving lymphatics and arteries. Ectopic veins as a possible source for varicocele persistence or recurrence were also ligated. Finally, an intraoperative venography with subsequent sclerotherapy was performed through one of the dissected veins.

RESULTS

Despite difficult anatomical situations after previous surgical interventions, the operations were performed successfully without any complications. Clinical controls showed varicocele disappearance without damage of the testis. No varicocele recurrence or persistence was observed.

CONCLUSIONS

This method combines the advantages of both methods. Precision of the microsurgical technique is combined with velocity of sclerotherapy. Thus, it may represent an interesting alternative to conventional operation methods especially in the treatment of recurrent or persistent varicoceles.

Frequency of natural rubber latex allergy in adults is increased after multiple operative procedures

BACKGROUND

It has been shown that immediate-type allergy to natural rubber latex (NRL) affects predominantly health-care workers and infants with malformations requiring repeated medical procedures. Adult patients with multiple invasive procedures are not thought to be at an increased risk of NRL allergy.

METHODS

A total of 325 consecutive adult inpatients (54.4+/-15.6 years; 219 men, 106 women) awaiting surgical or urologic procedures were assessed by questionnaire-based history (atopic diseases, number of previous standard operative or endoscopic procedures, intolerance to rubber products, and adverse reactions during medical care), by skin prick tests with different NRL test solutions, by measurement of NRL-specific IgE in the serum, and, if sensitization to NRL was found, by cutaneous challenge tests with NRL-containing material. Subjects were classified as sensitized to NRL if skin prick test reactions to NRL were positive or if NRL-specific IgE antibodies were found. NRL allergy was defined as NRL sensitization and immediate-type symptoms to NRL.

RESULTS

Thirty-one of 325 (9.5%) subjects were found to be sensitized to NRL, 14/285 (4.9%) by skin prick testing and 23/323 (7.1%) by NRL-specific IgE antibodies in the serum. Four individuals (1.2%) were diagnosed as having clinically manifest NRL allergy, and another 27 (8.3%) were sensitized to NRL without symptoms to date. The frequency of previous invasive procedures was zero in eight patients, up to 10 in 245, 11-20 in 52, 21-30 in seven, and over 30 (up to 83) in 13 patients. No association was found between the number of invasive procedures and NRL sensitization without clinical symptoms. However, 3/4 patients with NRL allergy had undergone more than 30 interventions, and 1/4 had had 11 operations. Frequent invasive procedures (more than 10) were significantly associated with NRL allergy (P<0.001). Allergy or sensitization to NRL was associated with atopy (21/31 vs 87/294) (P<0.001).

CONCLUSIONS

A remarkable percentage of unselected adult patients undergoing surgical procedures have allergy or sensitization to NRL. Repeated invasive treatment appears to be a risk factor for NRL allergy.

Endoscopic detection of transitional cell carcinoma with 5-aminolevulinic acid: results of 1012 fluorescence endoscopies

OBJECTIVES

The initial encouraging results using 5-aminolevulinic acid (5-ALA) induced fluorescence endoscopy (AFE) have promised a procedure with an outstanding sensitivity for the detection of early stage bladder cancer. Summarized here is our clinical experience and data comprising 1012 fluorescence endoscopies.

METHODS

Two hours, 30 minutes before endoscopy, 1.5 g 5-ALA dissolved in 50 mL of 5.7% sodium monohydrogen phosphate was instilled in patients intravesically. Before AFE, all patients underwent white light endoscopy, and a bladder washing cytologic specimen was obtained. A special light source provided blue light (375 to 440 nm) for fluorescence excitation. Suspicious sites were identified by their red fluorescence contrasting against backscattered blue light when observed through the long pass filter (445 nm) integrated into the telescope eyepiece.

RESULTS

Two thousand four hundred seventy-five specimens were obtained (2.4 biopsies per AFE). In 552 AFEs (54.5%), neoplastic urothelial lesions were detected, in 34.2% only because of their positive fluorescence; 38.7% of these additionally detected neoplastic foci had poorly differentiated histologic features.

CONCLUSIONS

AFE has proved to be a clinically feasible procedure with an outstanding detection rate for flat, urothelial, high-risk lesions.

Prospective study comparing human albumin vs. reinfusion of ultrafiltrate-ascitic fluid after total paracentesis in cirrhotic patients with tense ascites

Although, total paracentesis associated with human albumin substitution has shown to be a rapid, effective and safe treatment of diuretic refractory ascites in advanced liver cirrhosis, it implies high costs and has a limited availability. Therefore an alternative procedure the reinfusion of concentrated ascites has gained popularity in recent years (Smart et al. 1990; Grazioto et al. 1997). It was the aim of the study to compare human albumin substitution vs. reinfusion of ascitic-ultrafiltrate after total paracentesis. 35 patients with cirrhosis and tense ascites received total paracentesis associated with either human albumin (5-8 g/l ascites) (= group A) or reinfusion of an ascitic-ultrafiltrate fluid by means of hemofiltration technique (= group B). The mean volume of ascites removed was 9.41 (2.1-20.0) in group A and 11.41 (6.5-21.0) in group B. No significant differences in serum electrolytes, liver and renal function, coagulation profiles and hormones of the renin-angiotensin-aldosterone system were observed during hospitalization. In both groups sodium excretion increased significantly. 43% of the patients in group B developed pyrexia and chill after reinfusion of the ascitic-ultrafiltrate fluid. In one patient an anaphylactic bronchospasm occurred requiring IUC-treatment. The treatment cost in case of human albumin were 326.-DM vs. 290.-DM for each patient treated with ascitic-ultrafiltrate fluid reinfusion. The probabilities of hospital readmission and survival were similar in both groups during follow-up. The results indicate that i.v. infusion of ascitic-ultrafiltrate fluid is as effective as total paracentesis and albumin infusion in case of diuretic refractory ascites. However, according to the costs of instruments and staff and due to the significant allergic reactions caused by ascitic fluid it cannot be considered as a real alternative to albumin substitution.

Endoscopic fluorescence diagnosis and laser treatment of transitional cell carcinoma of the bladder

Recurrent bladder cancer is due to tumor cell implantation, incomplete resection, and multicentric neoplastic changes throughout the bladder. The possibilities of 5-Aminolevulinic acid-induced fluorescence endoscopy (AFE), a highly sensitive method in detecting bladder cancer and laser energy as treatment to lower the recurrence rate in bladder cancer, are evaluated. After intravesical administration of AFE Protoporphyrin IX, a tumor-selective manner is excited by a xenon-arc lamp (wavelength 400 to 410 nm) to emit red fluorescence. Suspicious lesions can be detected by their red fluorescence and are electroresected or treated with laser energy. Complete resection or destruction of all tumors in the bladder is crucial to prevent recurrent and invasive growth of transitional cell carcinoma. AFE detects malignant lesions in the bladder with a sensitivity of 98% and Cis in 100%, respectively. Laser treatment of superficial bladder cancer lowers the local recurrence rate and reduces the risk of viable tumor cell implantation.

Clonality and genetic divergence in multifocal low-grade superficial urothelial carcinoma as determined by chromosome 9 and p53 deletion analysis

Multifocality and recurrence are clinically important features of urothelial carcinomas of the urinary bladder. Recent molecular genetic studies have suggested that multifocal urothelial carcinomas are monoclonally derived from an identical transformed progenitor cell. However, most of these studies investigated advanced and poorly differentiated tumors. The study presented focuses on early papillary tumors, including 52 superficial well-differentiated multifocal and recurrent bladder carcinomas from 10 patients. Microdissection separating urothelium from stromal cells was considered essential to obtain pure tumor cell populations. Genetic analysis was carried out by applying two different methods. Dual color fluorescence in situ hybridization (FISH) with centromeric probes for chromosomes 9 and 17 and gene-specific probes for chromosome loci 9q22, 9p21, and 17p13 was carried out in parallel to loss of heterozygosity (LOH) analyses applying 5 microsatellite markers on these chromosomes. Overall, deletions on chromosome 9p were found in 47 tumors (90%), at chromosome 9q in 36 tumors (69%) and at chromosome 17p in 3 tumors (6%). There was a very high correlation of the results between FISH and LOH analysis. Ten early superficial papillary tumors showed deletion of chromosome 9p without deletion of 9q, suggesting 9p deletions as a very early event in the development of papillary urothelial carcinoma. Although in four patients, all investigated tumors showed identical genetic alterations and one patient showed no genetic alterations at the loci investigated, in five patients, two or more clones with different deletions were found. In four of these patients, the results are compatible with clonal divergence and selection of different cell subpopulations derived from a common progenitor cell. However, in one patient different alleles in two markers at chromosome 9 were deleted, favoring an independent evolution of two recurring tumor cell clones. In summary, we could show that there is considerable genetic heterogeneity in early multifocal and recurring urothelial carcinoma and demonstrated the occurrence of two independent clones in at least one patient as an indicator of possible initial oligoclonality of bladder cancer.

5-Aminolevulinic acid-induced fluorescence endoscopy for the detection of lower urinary tract tumors

The use of a photodynamic fluorescence marker for diagnosis of tumors is an intriguing concept to improve the thoroughness of surgical tumor resection. Complete surgical resection of multifocal bladder tumors and flat lesions such as carcinoma in situ is known to be difficult, and thus a source of recurrences. We report on the recent experience with the intravesical application of the photosensitizer prodrug 5-aminolevulinic acid (5-ALA), which is a nontoxic physiological heme substrate. Initial results from fluorescence diagnosis using krypton laser light, and recent results with a modified incoherent light source constantly showed a 25% increase in urothelial tumor detection in comparison to white light endoscopy. Due to the high sensitivity, the number of biopsies could be decreased constantly in comparison to routine random biopsies taken under white light endoscopy. The results show about 25-30% of cases with fluorescent lesions which are histologically benign. 5-ALA is a promising tool for the diagnosis of bladder cancer. The outcome of the admission study for 5-ALA in urology in Germany is positive, and is being continued by prospective multicenter clinical studies to prove the hypothesis of reduction of tumor recurrence with this method. 5-ALA-based fluorescence endoscopy is strongly recommended for further clinical testing.

Transurethral resection and surveillance of bladder cancer supported by 5-aminolevulinic acid-induced fluorescence endoscopy

PURPOSE

We determined whether neoplastic disease, which was missed under white light can be found during transurethral resection of bladder cancer by 5-aminolevulinic acid-induced porphyrin fluorescence.

MATERIALS AND METHODS

5-Aminolevulinic acid-induced fluorescence endoscopy was carried out in 328 cases. A 3% 5-aminolevulinic acid solution was instilled intravesically in a mean time of 2.8 h before endoscopy. The fluorescence was excited by a special incoherent light source which provided blue light in addition to white light.

RESULTS

In 82 (25%) cases additional neoplastic lesions were found only because of their red porphyrin fluorescence which was induced by 5-aminolevulinic acid. 31% of these neoplastic foci which were found in normal and nonspecific inflamed mucosa had a poorly differentiated histology.

CONCLUSIONS

5-Aminolevulinic acid facilitates detection of neoplastic disease during transurethral resection of bladder cancer and increases the accuracy of diagnosis.

Photodynamic cystoscopy for detection of bladder tumors

The use of a photodynamic fluorescence marker for diagnosis of tumors is an intriguing concept to improve thoroughness of surgical tumor resection. Complete surgical resection of multifocal bladder tumors and flat lesions as carcinoma in situ is known to be difficult, and thus a source of recurrencies. We report on the recent experience with the intravesical application of the photosensitizer prodrug 5-aminolevulinic acid (5-ALA), which is a nontoxic physiological heme substrate. Initial results from fluorescence diagnosis using krypton laser light and recent results with a modified incoherent light source constantly showed a 25% increase in urothelial tumor detection compared with white light endoscopy. Because of the high sensitivity, the number of biopsies could be decreased constantly compared with routine random biopsies taken under white light endoscopy. The results show about 25% to 30% of cases with fluorescent lesions, which are histologically benign. 5-ALA is a promising tool for diagnosis of bladder cancer. The outcome of the initial study of 5-ALA in urology in Germany is positive and is continued by prospective multicenter clinical studies to prove the hypothesis of reduction of tumor recurrence with this method. 5-ALA-based fluorescence endoscopy is strongly recommended for further clinical testing.