Diagnosis and metaphylaxis of stone disease. Consensus concept of the National Working Committee on Stone Disease for the upcoming German Urolithiasis Guideline

This review draws the recent state of the art in metabolic diagnosis and metaphylaxis of stone disease. It is the basis for the consensus approval with the other medical societies and institutions in Germany involved in the guideline process of the new "Urolithiasis Guideline". The German Working Committee on Stone Disease reviewed critically the current literature in the field of urolithiasis-including the existing German and EAU-Guidelines as well as the Conference Book of the First International Consultation on Stone Disease. As far as possible the references were rated according to the EBM criteria. On this basis the expert group discussed all pathways and statements regarding the management of stone disease. The present review coincides with the consented guideline draft of the German Working Committee on Stone Disease. Occurrence of stone disease in the western world increases seriously. Modern lifestyle, dietary habits and overweight-problems of the affluent societies-emerge to be the important promoters of the "stone-boom" in the new millennium. This even affects children, whose stone prevalence is otherwise significantly less than that of adults. Criteria for the high risk group of stone formers were clearly defined. A diagnostic standard is formulated for the basic and the elaborate metabolic evaluation of a stone patient. Approximately 75% of all stone patients could anticipate stone recurrence with elementary reorientation of their lifestyle and dietary habits, summarized as general metaphylaxis. About 25% of the stone formers require additional pharmacological intervention to normalize their individual biochemical risk, precisely compiled for each stone type as specific metaphylaxis.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

Clinical evaluation of a newly developed endoscopic resection device (Rotoresect): physical principle and first clinical results

BACKGROUND

Endoscopic resection techniques on benign prostatic tissue aim at a high ablation rate and a minimal bleeding rate. Although commercial resection electrodes are effective, they either cause high blood loss (loop electrode) or reduce the bleeding rate with a compromised ablation rate (electrovaporization electrode). To resolve these problems, a new electrosurgical resection device, The Rotoresect, has been developed.

METHODS

The Rotoresect incorporates a specially designed working element. The resection electrode is driven by a micromotor with a high-frequency current that enables simultaneous coagulation and vaporization during rotoresection. To date, 40 patients with benign prostatic hyperplasia have undergone transurethral rotoresection of the prostate with this new device.

RESULTS

The actively rotating resection electrode enables tissue coagulation and vaporization as well as mechanical tissue ablation. Only slight bleeding was observed during the entire resection procedure. Postoperatively, no significant changes in hemoglobin and sodium concentration were detected. The deobstructive effect of the Rotoresect was comparable to that of the standard loop.

CONCLUSIONS

The simultaneous tissue vaporization, coagulation, and mechanical removal by the Rotoresect enables a high ablation rate combined with minimal blood loss. Initial clinical results gained in the transurethral resection of benign prostatic tissue are promising.

What are the parameters for predictive selection of patients requiring anesthesia for extracorporeal shockwave lithotripsy?

OBJECTIVE

Additional anesthesia is required to minimize the tolerable pain level in efficiently performed extracorporeal shockwave lithotripsy (ESWL) with electrohydraulic and electromagnetic sources. In order to assess optimum anesthesia for each patient undergoing a standardized ESWL protocol, pain measurement and scoring were carried out. We attempted to determine the individual type and amount of analgesia prior to treatment.

METHODS

Patients (n = 95) with urolithiasis underwent pain measurement and scoring prior to ESWL. 'Threshold of pain' (TP) and 'maximal tolerable pain (MTP) were assessed by inducing ischemia pain with the submaximum effort tourniquet technique. Pain intensity was assessed by a verbal rating scale (VRS). The results of pain measurement and amount of analgosedation were correlated in two phases. Patients were administered an oral premedication of 0.1 mg/kg midazolam. Phase 1: 60 patients were randomized into three groups: (1) piritramide (0.1-0.3 mg/kg) and midazolam (1-3 mg) i.v. (2) Lidocaine/prilocaine cream topically (30 g) to skin and diclofenac supp. 100 mg. (3) No analgesia. Phase 2: Based on the data of phase 1, cut-off points for TP and MTP were set for female and male patients. In accordance with these results, 35 patients comprised group 1 for anesthesia with piritramide/midazolam, group 2 with lidocaine/prilocaine cream and diclofenac supp. and group 3 for no analgesia at all. The electromagnetic shockwave sources Modulith SLX and Lithostar Plus were utilized.

RESULTS

Phase 1: All patients randomized for group 1 (intravenous analgosedation) were treated in accordance with the protocol. 65% of group 2 (cream/suppository) tolerated treatment as planned. 35% of patients selected for ESWL without analgesia (group 3) remained within this group. Patients requiring additional analgosedation displayed lower TP and MTP. The cut-off points for females and males were TP >/=25/35 s and MTP >/=45/60 s, respectively. Phase 2: 20/35 patients were preselected for a nonintravenous protocol. Five out of these 20 violated the protocol. The rate of additionally administered analgesia was lower than in phase 1: 35:10% in group 2 (cream/supp.), 65:40% in group 3 (no analgesia).

CONCLUSIONS

The TP and MTP levels are lower in patients requiring stronger analgesia. The determined parameters are suitable for patient preselection and individual assessment of anesthesia prior to ESWL. It may be assumed that 50% of patients administered intravenous opioids are overtreated. Routine pain measurement for patient depends on the individual pain tolerance level. A third phase of this study recruiting a large number of patients will contribute to the confirmation of these results.