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.

Low Molecular Weight Heparin and Prevention of Postoperative Thrombosis in Abdominal Surgery

In a prospective, double-blind, randomized multicenter trial the efficacy and safety of low molecular weight heparin and unfractionated heparin were compared for the prevention of postoperative deep vein thrombosis in patients undergoing abdominal surgery. Six hundred and seventy-three patients were randomly allocated to the two prophylaxis groups; 20 of these, however, did not undergo surgery and did not receive any prophylaxis. Of the remaining 653 patients 323 received one subcutaneous injection of 3,000 anti-Xa units of low molecular weight heparin and 330 received subcutaneously 5,000 U heparin three times a day. Treatment was initiated 2 h preoperatively and continued for 7 to 10 days. The occurrence of DVT was determined by the 125I-labelled fibrinogen uptake test and phlebography. Venous thrombosis was diagnosed in 24 of 323 patients (7.4%) treated with low molecular weight heparin and in 26 of 330 patients (7.9%) treated with low-dose heparin. DVT of proximal veins was detected in four patients of the low molecular weight heparin group and in three patients of the low-dose heparin group. During the observation period three pulmonary emboli - one fatal and two non-fatal - occurred in patients receiving prophylaxis with low-dose heparin. No pulmonary embolism was found in patients treated with low molecular weight heparin. Both prophylactic schemes were well tolerated. Intra-and postoperative blood loss, incidence of wound hematoma, frequency and volume of intra- and postoperative blood transfusion were similar in both groups with a slight advantage for the low molecular weight heparin group. The results of this trial show that the investigated low molecular weight heparin is at least as effective and safe as low-dose heparin in preventing deep vein thrombosis in patients undergoing elective abdominal surgery.

[Antibiotic stewardship (ABS). Definition, contents, necessity and practice on examples of current clinical-urological controversies]

BACKGROUND

Infectious diseases caused by multi-resistant pathogens are increasing worldwide and are posing a challenge to German urology as well. Furthermore, there is a limited perspective of new antibiotic developments. One way out of this dilemma is a differentiated handling and use of antibiotics (antibiotic stewardship, ABS).

AIM

The aim of this review is to identify key issues in modern urological antibiotic therapy, which can be considered as exemplary for the whole topic of ABS. This includes a review of the current data of the individual topics, including thought-provoking impulse for future clinical application and research.

MATERIAL AND METHODS

The research group "infectious diseases" of GeSRU Academics identified the following central topics: excessive use of fluoroquinolones, diagnosis and treatment of urethritis and perioperative antibiotic prophylaxis. Subsequently, we performed a literature research in MEDLINE to uncover controversies and open questions of the individual topics within the meaning of ABS.

RESULTS

The analysis of modern antibiotic therapy in urology shows numerous open questions in all quality dimensions of ABS: structural quality (e.g. through improved training of medical staff in the differentiated use of antibiotics), process quality (e.g. by improved adherence to existing infectiological guidelines, here in particular the perioperative prophylaxis and therapy of urethritis) and outcome (e.g. by detection of resistance rates and infection rates).

DISCUSSION

The overarching and common goal is to avoid a post-antibiotic era. ABS programmes and a 10-point plan of the federal government are considered positive political developments in this area but do not release the individual urologist from a personal responsibility as part of his daily routine. A critical analysis of the topic "antibiotic treatment" is essential.

Bicentric prospective evaluation of corporoplasty with porcine small intestinal submucosa (SIS) in patients with severe Peyronie's disease

INTRODUCTION

Advanced Peyronie's disease (PD) with severe penile deviation demands grafting procedures following plaque incision or partial plaque excision in order to avoid penile shortening and to improve quality of life of affected patients. Small intestinal submucosa (SIS) is an established xenograft. The objective of the present study was to validate external results in a bicentric prospective manner.

METHODS

Patient selection criteria, surgical technique and standards for pre- and postoperative care were defined. Consecutively, patients with severe penile deviation in stable disease and sufficient erectile function were included between 2007 and 2015. After plaque incision, grafting was performed using SIS in a standardized manner. The postoperative evaluation using a non-validated questionnaire included complications, correction of curvature, pre- and postoperative erectile function, change in penile length and general satisfaction with the procedure.

RESULTS

Forty-three patients underwent surgery between 2007 and 2015. The mean degree of preoperative curvature was 73.8° (range 60-90°). No intraoperative or major postoperative complications were reported. After a mean follow-up of 33.0 months (range 10-59), complete straightening of the penis was achieved in 74.4%. 88.4% of all patients were able to achieve satisfying sexual intercourse (67.4% unaided, 21.0% with assistance). The IIEF-5 score was improved in 69.8% (mean improvement 4.0 points). Overall 86.0% were satisfied with the surgical treatment.

CONCLUSION

Corporoplasty with SIS in patients with PD and severe penile curvature is a safe approach and shows good long-term results. A thorough patient selection and a standardized pre-, intra- and postoperative procedure are decisive for a satisfying outcome.

Oncological outcome of primary versus secondary muscle-invasive bladder cancer is comparable after radical cystectomy

BACKGROUND

High-risk non-muscle-invasive bladder cancer (NMIBC) progressing to muscle-invasive bladder cancer (MIBC) is associated with adverse tumour biology. It is unclear, however, whether outcome of NMIBC progressing to MIBC is adverse compared to primary MIBC and whether NMIBC of higher risk of progression to MIBC is adverse compared to NMIBC of lower risk.

OBJECTIVE

Our objective was to assess cancer-specific survival (CSS) following radical cystectomy (RC) for primary MIBC and for NMIBC progressing to MIBC in dependence of EORTC risk score.

MATERIALS AND METHODS

Clinical and histopathological characteristics and CSS of 150 patients were assessed. Secondary MIBCs were stratified by EORTC risk score at the last transurethral resection of bladder tumour for NMIBC.

RESULTS

CSS did not differ significantly between primary and secondary MIBC (p = 0.521). Secondary MIBC with high EORTC score had significantly shorter CSS compared to secondary MIBC with intermediate EORTC score (p = 0.029). In multivariable analysis, pathological tumour stage (HR = 3.77; p = 0.020) and lymph node stage (HR = 2.34; p = 0.022) were significantly correlated with CSS.

CONCLUSION

While the outcome of secondary MIBC is not generally adverse compared to primary MIBC, the EORTC risk score not only reflects high risk of progression of NMIBC to MIBC, but also worse outcome following RC for secondary MIBC. Timely RC should thus be debated in high-risk NMIBC.

Management of early-invasive high-grade transitional cell carcinoma of the bladder

The decision in favor or against an early cystectomy in patients with initial pT1G3 urothelial carcinoma of the bladder (UCBC) is challenging. In the present review the authors dwell on the key issues in the controversial discussion about optimal management of so called ''early invasive'' UCBC. The quality of transurethral resection of the bladder tumor (TURBT) as diagnostic and therapeutic method plays an important role. Histopathological assessment delivers crucial risk factors for stratification. Last but not least life quality under different therapeutic regimes should be comprised in the decision process.

Comparison of 3,000 IU aXa of the low molecular weight heparin certoparin with 5,000 IU aXa in prevention of deep vein thrombosis after total hip replacement. German Thrombosis Study Group

BACKGROUND

The aim of this randomized, double-blind and prospective clinical trial was to investigate whether an increase of the conventional daily dosage (3,000 IU aXa) of the low molecular weight heparin certoparin up to 5,000 IU aXa/day might lower the incidence of deep vein thrombosis (DVT) in patients undergoing elective hip surgery.

METHODS

The main criterium of this trial was the incidence of DVT diagnosed by bilateral ascending venography, which was performed either if DVT was clinically suspected or in each remaining patient between the 12th and the 14th postoperative day. A total number of 172 patients were enrolled to receive the conventional dosage of 3,000 IU aXa (Mono-Embolex NM) and 169 patients to receive the high dosage form (5,000 IU aXa) once daily. The mean age (+/-SD) was 69.6+/-9.5 and 67+/-11.7 years.

RESULTS

No relevant differences were found concerning predisposing risk factors. The duration of surgery was 93+/-25.2 and 88+/-21.4 min (mean+/-SD). Surgical type and approach were not different between the groups. Deep vein thrombosis was detected in 17 patients (9.9%) in the conventional dose group and in 16 patients (9.5%) in the high dose group (intent-to-treat analysis; n.s.). The rate of bleeding complications was not significantly different except the cell saver volumes (770+/-136 vs 475+/-186 ml; p<0.001). No significant difference was found in the serious adverse event reporting along the lines of EC-GCP (10 vs 8 events; p=0.65).

CONCLUSIONS

This clinical trial confirmed that the conventional dosage (3,000 IU aXa/day) of certoparin ensures maximal antithrombotic activity.

Low molecular weight heparin and prevention of postoperative thrombosis in abdominal surgery

In a prospective, double-blind, randomized multicenter trial the efficacy and safety of low molecular weight heparin and unfractionated heparin were compared for the prevention of postoperative deep vein thrombosis in patients undergoing abdominal surgery. Six hundred and seventy-three patients were randomly allocated to the two prophylaxis groups; 20 of these, however, did not undergo surgery and did not receive any prophylaxis. Of the remaining 653 patients 323 received one subcutaneous injection of 3,000 anti-Xa units of low molecular weight heparin and 330 received subcutaneously 5,000 U heparin three times a day. Treatment was initiated 2 h preoperatively and continued for 7 to 10 days. The occurrence of DVT was determined by the 125I-labelled fibrinogen uptake test and phlebography. Venous thrombosis was diagnosed in 24 of 323 patients (7.4%) treated with low molecular weight heparin and in 26 of 330 patients (7.9%) treated with low-dose heparin. DVT of proximal veins was detected in four patients of the low molecular weight heparin group and in three patients of the low-dose heparin group. During the observation period three pulmonary emboli - one fatal and two non-fatal - occurred in patients receiving prophylaxis with low-dose heparin. No pulmonary embolism was found in patients treated with low molecular weight heparin. Both prophylactic schemes were well tolerated. Intra- and postoperative blood loss, incidence of wound hematoma, frequency and volume of intra- and postoperative blood transfusion were similar in both groups with a slight advantage for the low molecular weight heparin group.(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylaxis of deep vein thrombosis in high risk patients undergoing total hip replacement with low molecular weight heparin plus dihydroergotamine

In 160 high risk patients with total hip replacement the antithrombotic efficacy and tolerance of a single daily injection of 1500 aPTT-U (aPTT = activated partial thromboplastin time) low molecular weight heparin plus 0.5 mg dihydroergotamine (HNMD; Embolex NM) was compared with a twice daily application of 5000 IU of the heparin-dihydroergotamine combination Heparin-Dihydergot in a double-blind study. Deep vein thrombosis measured by means of the radiofibrinogen uptake test occurred in 20.5% of patients in both groups. In addition, intra- and postoperative blood loss and the development of hematoma were similar in both groups. Thus, on account of the "once-daily" application HNMD offers some substantial advantages: The stress of the patient in the postoperative convalescence phase can be appreciably lowered and thereby the nursing staff are spared a great deal of work.

[Studies about combined lesions - 30th communication. Activation and inhibition of blood-coagulation after whole-body irradiation combined with trauma (author's transl)]

45 rabbits of both sexes were divided into five groups. Animals were sham irradiated, inflicted with an autologous haematoma as a trauma, whole-body irradiated with 500 RX-rays, and inflicted with a combination of irradiation and autologous haematoma or skin-wound. Already 24 hr after irradiation a highly significant prolongation of the activated partial thromboplastin-time was observed. The concentrations of factor X and fibrinogen increased in all irradiated animals 24 hr after irradiation. Following the combination injury of irradiation and skin-wound such increases were significantly higher than those after irradiation alone. The activities of antithrombin III and antiplasmin, measure with chromogen substrates, rose after irradiation as well as after combined injuries. In spite of the increased level of fibrinogen we could register hypocoagulability with significant increase of activation as well as of inhibition of the plasmatic coagulation system 24 hr after combined injuries.