[Clinical approach to renal trauma]

Management of kidney injuries is an uncommon challenge to urologists. Therapy has evolved in recent years from mainly surgical to predominantly conservative treatment. Immediate surgical intervention for renal trauma is now only necessary in rare instances. This overview is based on the guidelines of the European Association of Urology and the Societé International d'Urologie as well as clinical experience and is intended to provide practical advice for treatment of renal trauma.

[Impact of immunotherapy in metastatic kidney cancer in Germany after introduction of new target therapy--results of a telephone survey of the German Society of Immuno- and Targeted Therapy (DGFIT)]

INTRODUCTION

Until recently, the standard therapy for metastatic renal cell carcinoma (mRCC) in Germany consisted of interleukin-2 (IL-2), interferon-alfa (IFN) as single agents or in combination, with or without chemotherapy. Since 2005, new drugs (target drugs) in the therapy for mRCC are available. The aim of this study was to analyse the current therapy standard in Germany.

METHODS

By representative telephone interviews (GFK-Nürnberg by order of DGFIT) the following colleagues were contacted A: urologists in private practice (n = 40), B: oncologists in private practice (n = 40), C: hospital urologists (n = 35) and D: hospital oncologists (n = 35). Screening criteria were 1) responsibility for therapy in mRCC; 2) therapy of at least 10 patients with mRCC per year.

RESULTS

Patients/year: A: n = 19, B: n = 17, C: n = 43, D: n = 21. 98% of patients with mRCC were treated: A: the most frequent therapy was sunitinib (43%, 42%, 33% as first-, second-, third-line), B: the most frequent therapy was sunitinib (45% as first-line, 37% as second-line), the most frequent third-line therapy was sorafenib (35%); C: the most frequent therapy were sorafenib and sunitinib (first-line 26% vs. 27%, second-line 46% vs. 42%), in third-line therapy additionally temsirolimus 24%; D: primary sorafenib and sunitinib (first-line 33% vs. 40%, second-line 46% vs. 42%), in third-line therapy additionally temsirolimus 23%. Immunotherapy (IL-2, IFN with or without chemotherapy) in mRCC plays in Germany for the second- and third-line therapy in A-D no major role (less than 10%). Otherwise, for first-line therapy immunotherapy has some relevance: A: 25%, B: 37%, C: 33%, D: 16%. The most important criteria for therapy decision making in A-D were: efficacy, toxicity, drug approval status.

CONCLUSIONS

Most patients with mRCC in Germany were seen by hospital urologists. Sunitinib (in first-line) and sorafenib (in second-line) are currently the most frequent prescribed drugs in mRCC. Temsirolimus is used mostly for third-line therapy (followed by sunitinib/sorafenib). Treatment of mRCC in Germany is increasingly being performed by oncologists.

Perioperative blood loss in open retropubic radical prostatectomy - Is it safe to get operated at an educational hospital?

Introduction

Blood loss during radical prostatectomy has been a long term issue. The aim of this study was to investigate the influence of the training level of the first assistant regarding blood loss in open retropubic radical prostatectomy at an educational hospital.

Material and methods

364 patients underwent radical prostatectomy from 11/2006 to 10/2007 at one institution operated by one surgeon. In 319 patients all predefined parameters were obtained. Training level was determined by year of residency (1-5 yrs) or consultant status. Perioperative blood loss was calculated using three parameters: Hemoglobin level before and after surgery, postoperative sucker volume and weight of compresses. Furthermore the influence of prostatic size and BMI was analyzed.

Results

The Hb-decrease 24 h postoperatively was 2.4 g/dl median (-0.4-7.6 g/dl); sucker volume was 250 ml median (10-1500 ml); weight of compresses and swabs was 412 g median (0-972 g). One patient needed a transfusion with two erythrocyte concentrates one day after the surgery. There was no significant correlation regarding Hb-decrease (p = 0.86) or sucker volume plus weight of compresses (p = 0.59) in regard to the years of residency of the assisting physician. Also the number of assisted operations (n = < or > 20) had no significant influence on calculated blood loss (p = 0.38).

Conclusions

For an experienced surgeon the impact of the assistant regarding blood loss seems negligible. The training level of the assistant was not significantly correlated to a rise or decrease of perioperative blood loss. In our data radical prostatectomy could be safely performed at an educational hospital independent of the training level of the first assistant.

Long-term safety of sorafenib (SOR) for the treatment (tx) of advanced clear-cell renal-cell carcinoma (RCC): Data analysis from patients (pts) treated for over 1 year in the phase III TARGET study

e16057

Background: Results of the phase III multicenter TARGET study, a randomized, double-blind, placebo (PBO)- controlled study of tx with SOR in pts with clear-cell RCC in whom 1 prior systemic therapy had failed, indicated that SOR is effective (PFS 5.5 vs 2.8 mo, HR=0.44, P<0.000001, and 39% increase in survival for SOR vs PBO, HR=0.71, P=0.015) and safe in pts with advanced RCC (Escudier et al. N Engl J Med. 2007). With a database cut-off of Sept 8, 2006, we analyzed the safety of long-term use of SOR in pts in TARGET (study start Nov 2003). Methods: Pts (N=903) with advanced metastatic clear-cell RCC that had progressed after 1 systemic tx, ECOG PS 0–2, and low- or intermediate-risk MSKCC score were randomized 1:1 to SOR 400 mg BID or PBO. End points included OS, PFS, and safety. A single planned analysis of PFS showed a significant benefit of SOR over PBO; consequently, pts assigned to PBO were offered SOR. Descriptive analysis of safety and efficacy of pts treated >1 year (y) was conducted. Results: 169/903 pts were randomized to SOR and treated >1 y and 27 pts treated >2 y. Due to crossover of PBO to SOR, only 6 pts randomized to PBO were treated with SOR >1 y. Pts treated with SOR >1 y had median PFS of 10.9 months and a response rate of 22.5%. Median tx duration was 20 months. Drug-related adverse events (AEs) were mainly grades 1 and 2 and occurred early during tx (see Table ); 31% and 22% of pts required dose interruption and reduction, respectively, because of AEs. Conclusions: Long-term tx with SOR did not result in new toxicities or an increase in overall incidence of tx-related AEs. Toxicity was not cumulative and no increase in grades 3/4 AEs was observed. Pts with preexisting cardiac disease or hypertension tolerated long-term tx with SOR; no dose reduction was required. No increase in cardiovascular toxicity was observed in this pt population. Long-term tx of pts with advanced RCC with SOR is medically manageable, with a predictable AE profile. [Table: see text]

[Table: see text]

Multislice computed tomography versus contrast-enhanced ultrasound in evaluation of complex cystic renal masses using the Bosniak classification system

To assess the diagnostic performance of multislice computed tomography (MS-CT) in the classification of atypical or complex cystic renal masses using the Bosniak system in comparison to contrast-enhanced ultrasound (CEUS) and, in unclear cases, to the surgery findings.Thirty-two consecutive patients (14 women, 18 men; age range 39-72 years) with 37 atypical or complex cystic renal masses at MS-CT underwent conventional ultrasound (US) and CEUS. CEUS employed a low-MI technique using 1.6-2.4 ml SonoVue (Bracco, Italy) i.v. and a 2-4 MHz multifrequency transducer (Siemens, Sequoia, Acuson). Fourteen masses were resected, the remaining 23 lesions were followed up for periods ranging from 3 months to 2 years. Images and digital cine clips of all lesions were evaluated by blinded readers. On the basis of MS-CT appearance the lesions were assigned to the Bosniak classification. Similar criteria modified for US imaging were used to score atypical cysts at CEUS. In the Bosniak classification at MS-CT the lesions were scored as category II (n=15), IIF (n=7), III (n=8) and IV (n=7). At CEUS, masses were classified as Bosniak classification II (n=8), IIF (n=12), III (n=8) or IV (n=9). All type IV and 6/8 type III and 1/8 type IIF lesions were removed surgically. All category IV and 3/8 category III lesions of the surgical group were malignant, the one type IIF lesion was benign. All class II and IIF cysts except one were stable after a follow-up period ranging from 3 months to 2 years. In 7/37 lesions (19%) the MS-CT and CEUS scores were different, while in 30/37 (81%) they were equivalent. CEUS depicted more thin septa than MS-CT, or upgraded wall thickness, resulting in a Bosniak score upgrade from category II to IIF in 5 lesions. Two cystic renal masses could not be clearly assigned by MS-CT but were considered malignant due to the additional information from CEUS, which was confirmed by surgical removal (small cystic renal cancer).CEUS with SonoVue allows an early evaluation of atypical or complex cystic renal masses. It is an additional examination to MS-CT. Due to the dynamic examination, additional information about perfusion of the cystic septa or cystic renal cancer can be gained.

[Technical aspects of intraoperative assessment of treatment progress in laser lithotripsy]

BACKGROUND

During laser-induced fragmentation, differences in assessing the intraoperative results can depend on the individual characteristics of the laser system used.

METHODS

Laser parameters like pulse energy and repetition rate, the penetration depth in silicon tissue, and the laser beam width on photographic paper were determined for three different clinical laser systems.

RESULTS

Pulse energy and repetition rate were subject to variations depending on the laser system employed. Significant differences between the three devices were found for penetration depth in silicon and interaction.

CONCLUSIONS

Further investigations to ascertain the ablation threshold and fragmentation rate can be based on these findings. Intraoperative assessment of the lithotripsy results should take technical aspects of the laser equipment, stone consistency, and the surgeon's experience into consideration.

A phase I study to evaluate safety, immunogenicity and anti-tumor activity of the multi-peptide vaccine IMA901 in renal cell carcinoma patients (RCC)

5098

Background: IMA901 is a therapeutic cancer vaccine based on multiple synthetic tumor-associated peptides confirmed to be naturally presented by analysis of primary RCC tissues. IMA901 consists of 9 HLA-class I-binding and 1 HLA class II-binding peptides with the capacity to activate cytotoxic T cells (CD8+ T cells) and T helper cells (CD4+ T cells). Methods: 30 patients with stage III/IV RCC were enrolled in a single arm, multi-centre study. The endpoints were safety, T-cell responses, pharmacokinetics of the intradermal application of GM-CSF and anti-tumor activity according to RECIST. Patients had to be HLA-A*02 positive and received 8 intradermal vaccinations on days 1, 2, 3, 8, 15, 22, 36 and 64 each consisting of 4.5 mg IMA901 and 75 μg GM-CSF. Results: The most prevalent adverse events (AEs) were fatigue, cough and headache. Aseptical lymphadenitis and injection site reactions such as erythema, edema and pruritus were the most frequent possibly drug-related AEs. All possibly drug-related adverse events were mild to moderate. No patient experienced any possibly drug-related serious adverse events or deaths during the study. Pharmacokinetic data provided no evidence for accumulation of GM-CSF upon repeated i.d. administration. 74% of patients showed a vaccine-induced specific T-cell response and 30% of patients responded to multiple peptides contained in IMA901. The overall tumor assessment in patients with measurable disease revealed that 8 patients (35%) demonstrated a clinical benefit (1 PR + 7 SD). Most encouraging, patients who elicited multiple T-cell responses showed a statistically significant higher clinical benefit rate. Conclusions: IMA901 is safe, very well tolerated and immunogenic. Clinically observed tumor growth control in RCC patients may imply anti-tumor activity strongly supported by two patients with tumor regression (1 PR and 1 patient with 27% shrinkage in target lesions). The mode of action is strongly supported by the finding that multiple T-cell responders were significantly more likely to have a clinical benefit. These data clearly support the further development of IMA901.

No significant financial relationships to disclose.

Randomized phase II trial of first-line treatment with sorafenib versus interferon in patients with advanced renal cell carcinoma: Final results

5025

Background: This trial investigated the efficacy and safety of sorafenib (SOR) vs interferon (IFN) in treatment-naïve patients with clear-cell renal cell carcinoma (RCC). Methods: Previously untreated patients with advanced RCC were randomized to continuous oral SOR 400 mg bid or IFN 9 million units tiw (part 1), with an option of dose escalation to SOR 600 mg bid or crossover from IFN to SOR 400 mg bid upon disease progression (part 2). The primary endpoint was progression-free survival (PFS). Results: Baseline characteristics (ITT, n=189) were similar in SOR (n=97) and IFN (n=92) groups. In the IFN arm, 90/92 patients received treatment; 56 had disease progression, of which 50 crossed to SOR. All 97 patients in the SOR arm received SOR 400 mg bid; 65 had disease progression, of which 44 were dose escalated to 600 mg bid. In part 1, 5% vs 9% patients had complete/partial response, disease control rate (complete/partial response + stable disease) was 79% vs 64%, and median PFS was 5.7 months (CI: 5.0–7.4 months) vs 5.6 months (CI: 3.7–7.4 months) for SOR vs IFN, respectively. Progression-free rates for SOR vs IFN were 90.0% vs 70.4%, 45.9% vs 46.5%, and 11.5% vs 30.4% at 3, 6, and 12 months, respectively. A total of 11% vs 15% of patients receiving SOR or IFN, respectively, discontinued due to adverse events. Overall, the incidence of adverse events was similar between both treatment arms, although skin toxicity (rash and hand-foot skin reaction) and diarrhea occurred more frequently in the SOR group, and flu-like syndrome occurred more frequently in the IFN group. In part 2, median PFS was 5.3 months (CI: 3.6–6.1 months) in patients (n=50) who crossed from IFN to SOR. The median PFS for patients (n=44) with dose escalation to 600 mg bid was 3.6 months (CI: 1.9–5.3 months). The 600 mg bid dose was well tolerated. Conclusions: Although the primary endpoint (PFS) was not reached, SOR showed activity in first-line treatment of RCC based on disease control rate. PFS benefit was observed in patients who crossed to SOR 400 mg bid after progression on IFN. Patients who were dose escalated to 600 mg bid after progression had disease stabilization for a further 3.6 months. Further analyses of possible benefit from SOR dose escalation are required in a larger number of patients.

[Table: see text]

Correlation of T-cell response, clinical activity and regulatory T-cell levels in renal cell carcinoma patients treated with IMA901, a novel multi-peptide vaccine

3017

Background: Cancer vaccines have been able to induce T-cell responses in cancer patients but rarely demonstrated a correlation of immune responses with clinical benefit. Here, we present immunological results of a phase 1 study with IMA901, a therapeutic cancer vaccine based on multiple novel synthetic tumor-associated peptides (TUMAP) identified as being naturally presented in primary renal cell carcinoma (RCC) tissues. Methods: The HLA peptidome of 32 primary RCC samples was systematically investigated using a combination of mass spectrometry, gene expression profiling and in vitro human T-cell assays. 9 HLA-A*02- and 1 HLA-DR- restricted TUMAPs derived from 9 different tumor antigens were selected and designated IMA901. 28 HLA-A*02-positive stage III/IV RCC patients were enrolled in a single arm, multicenter study and received 8 vaccinations on days 1, 2, 3, 8, 15, 22, 36, and 64 each consisting of 4.5 mg IMA901 (including a HBV-derived viral marker peptide) and 75 μg GM-CSF as immune adjuvant. T-cell responses using IFN-γ ELISPOT and HLA multimer analysis and CD4+ Foxp3+ regulatory T cell (Treg) levels were measured in peripheral blood. Results: In vivo IMA901- induced specific T-cell responses were detected to the HBV marker peptide (52% of 27 evaluable patients), at least one TUMAP (74%) or multiple TUMAPs (30%). T-cell responses were detectable already at day 15, peaked subsequently and were sustainable until follow-up in the majority of patients. Most importantly, patients eliciting multiple responses to TUMAPs significantly showed a higher clinical benefit rate (SD+PR; p=0.018) and lower Treg levels at study onset (p=0.016). No correlation of HBV marker peptide responses with either clinical benefit or Treg levels was observed. Conclusions: IMA901 rapidly induced T-cell responses in a majority of advanced RCC patients. A clinical mode of action is strongly supported by the significant correlation of multiple T-cell responses with clinical benefit. CD4+ Foxp3+ Tregs seem to play an active role in limiting the broadness of T-cell responses. Furthermore, our data suggest that we can predict in vivo immunogenicity of cancer vaccine antigens by our in vitro drug discovery approach.

No significant financial relationships to disclose.

Contrast enhanced ultrasound eases interpretation of an unclear renal tumor in addition to CT, MRI and histological findings--a case report in a young patient

Renal cancer represents accounts for approximately 3% of all adult malignancies with a rising incidence. Incidental diagnosis is mostly based upon ultrasound (US). US and Computed tomography (CT) are the standard imaging modalities for detecting renal cell cancer (RCC). Differentiation between malignant and benign renal tumors is of utmost importance. Contrast enhanced ultrasound (CUS) seems to be a promising new diagnostic option for diagnosis and preoperative treatment planning for patients with renal cancer. It is an additional examination to baseline ultrasound and CT. We report a case of a 37-year-old woman with a papillary renal cell cancer in which CUS helped to differentiate dignity of the tumor. CUS is an additional examination to baseline ultrasound and CT. It is a less invasive technique than contrast enhanced CT and shows even slight tumor blood flow. In addition it may allow a more rapid diagnosis, because of its bedside availability.

[Genital herpes]

Genital herpes simplex virus (HSV-1 and HSV-2) infection is an ulcerative, lifelong, recurring sexually transmitted disease of increasing epidemiologic worldwide importance. Transmission occurs by close skin contact, usually during asymptomatic virus shedding. The virus persists in the dorsal root ganglion where it is not accessible to the host's immune system. The most important risk factor is a person's number of lifetime sex partners. The more extensive first-episode infection is followed by milder recurrences. Recurrence rates differ greatly. The diagnosis is made clinically, microbiologically, and serologically. There are several virostatic agents available for treatment.

Adverse effects of drug therapies on male and female sexual function

Sexual dysfunctions (SD) are adverse effects of common drug therapies that have rarely been considered in investigations so far. Possibly it is barely known that many widespread and frequently prescribed medications and drug therapies can have significant impact on vascular and nerval processes as well as on endocrinologic and psychoneuroendocrinologic systems and therefore can influence sexual functions. Impotence and disorders of the erectile function can mainly be caused by antidopaminergic mechanisms, whereas ejaculatory disorders and anorgasmia often can be explained by antiserotoninergic effects. Anticholinergic and adrenoloytic agents can also cause a particular impairment of erectile functions. The following considerations will show that the detection and treatment of SD (also in women!) should be given much more attention since drug-induced SDs occur predominantly in indications where a SD itself can be a symptom of the disease.

Antiangiogenetische Therapie beim Nierenzellkarzinom

Sunitinib and Sorafenib are both effective angiogenetic inhibitors for the treatment of renal cell carcinoma. With these drugs of a new class of chronic therapy is performed. During chronic treatment, the inherent side effects may necessitate stopping the application of these drugs thus preventing the required effective therapy. Most of the effects can be avoided or attenuated by prophylaxis. In this paper the published data are reviewed and added with our experience in 138 patients over up to two and a half years.

Randomized phase III trial of sorafenib in advanced renal cell carcinoma (RCC): Impact of crossover on survival

4524

Background: Sorafenib was approved for advanced RCC in the USA December 2005. A Phase III randomized double-blind, placebo-controlled trial demonstrated an estimated 39% improvement in survival for patients receiving sorafenib versus placebo (HR= 0.72, p = 0.018) (ECCO 2005). These data supported independently reviewed doubling of PFS to 24 weeks in RCC patients receiving sorafenib compared with placebo (12 weeks) (p < 0.000001) (ASCO 2005). Based on the statistical significance and magnitude of PFS benefit, patients were unblinded and placebo patients allowed to crossover to sorafenib in April 2005. A prospectively planned interim OS analysis reflecting impact of crossover of placebo patients is presented. Methods: OS data up to November 30, 2005, were analyzed in this interim analysis using a stratified log-rank test comparing the two treatment groups. In order to examine the effect of crossover on OS, a secondary analysis was performed censoring data from patients randomized to placebo at June 30, 2005. Results: A total of 903 patients were randomized (451 to sorafenib, 452 to placebo) and >200 placebo patients crossed over to sorafenib. Baseline characteristics were similar between treatment arms. There were 367 deaths. The median OS was 19.3 months for sorafenib versus 15.9 months for placebo (HR = 0.77; 95% CI 0.63, 0.95; p = 0.015); although this did not attain the level of significance specified for the interim analysis (α = 0.009), a continued favorable trend in survival benefit was observed. With censoring of crossover data, the median OS was 19.3 months for sorafenib versus 14.3 months for placebo (HR = 0.74, 95% CI 0.58, 0.93; p = 0.010). Conclusion: Sorafenib is the first novel, oral approved treatment for advanced RCC in more than a decade. Previous information on the effect of crossover on OS in randomized oncology studies is limited. The lower HR observed after censoring placebo patients crossed over to sorafenib suggests a continued beneficial effect of sorafenib. Final results await more mature data.

[Table: see text]

Randomized phase II trial of the multi-kinase inhibitor sorafenib versus interferon (IFN) in treatment-naïve patients with metastatic renal cell carcinoma (mRCC)

4501

Background: Sorafenib, an oral multi-kinase inhibitor that targets tumor growth and vascularization, significantly prolonged PFS in a Phase III trial with previously treated mRCC patients. This randomized Phase II trial investigated the efficacy and tolerability of sorafenib compared with IFN in first-line therapy of patients with clear-cell RCC. Methods: Untreated patients with mRCC were stratified by MSKCC prognostic score and randomized to receive continuous oral sorafenib 400 mg bid or IFN 9 million units tiw, with an option of dose escalation (600 mg bid sorafenib) or crossover from IFN to sorafenib upon disease progression. The study assessed PFS at 99 events as primary objective, best response (RECIST), overall survival, health-related quality of life, and adverse events (AEs). Results: Baseline characteristics of 188 patients (sorafenib n=97; IFN n = 91) were: median age 62.0 years; MSKCC score: 57% low, 41% intermediate, 1% high; prior nephrectomy: 82%; ECOG 0:1, 55.3%:44.7%. As of January 6, 2006, PFS events have been reported for 64 (34%) patients. Preliminary data showed drug-related AEs of any severity (sorafenib vs IFN) in 50.5% vs 51.6% of patients (≥grade 3: 8.2% vs 11.0%), including diarrhea (24.7% vs 5.5%), fatigue (14.4% vs 20.9%), fever (2.1% vs 18.7%), hypertension (13.4% vs 0%), nausea (5.2% vs 13.2%), flu-like syndrome (1.0% vs 6.6%), hand-foot skin reaction (6.2% vs 0%), and rash/desquamation (4.1% vs 0%). Drug-related metabolic/laboratory abnormalities at grade 3 (no grade 4) comprised hypophosphatemia (21.7% vs. 0%), lipase elevation (5.6% vs. 11.1%), anemia (0% vs. 5.3%) and hypoalbuminemia (0% vs. 3.6%). Five patients receiving IFN withdrew from treatment due to AEs, whereas only one patient withdrew from sorafenib. Conclusions: Sorafenib was generally well tolerated in RCC patients in the first-line setting, with relatively infrequent drug-related AEs ≥grade 3. Full PFS data will be presented at the meeting.

[Table: see text]

[Therapy strategies for advanced renal cell carcinoma]

The therapeutic regimen for metastatic renal cell cancer has changed substantially in the last years. Formerly, metastatic disease was regarded as being inoperable and had a disastrous prognosis. Nowadays, radical nephrectomy is the accepted urologic-oncologic standard therapy in metastatic primaries, if technically feasible. A complete resection of metastases may be curative, or can achieve a substantial palliative benefit. A better understanding of prognostic parameters helps in the selection of patients with a chance of benefiting from systemic immunochemotherapy. For patients with rapidly progressing tumors or sarcomatoid dedifferentiation, new effective chemotherapy regimens are available. New angiogenesis inhibitors such as sutent, avastin or sorafenib can potentially be effectively used in future therapeutic regimens.

Targeted Agents for the Treatment of Advanced Renal Cell Carcinoma

Renal cell carcinoma (RCC) is a highly treatment-resistant tumor type; however, advances in elucidating the molecular pathophysiology underlying RCC has led to the identification of promising targets for therapeutic intervention. In clear-cell RCC, mutations to the von Hippel-Lindau (VHL) gene results in the up regulation of many proteins necessary for tumor growth and survival--such as vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and platelet derived growth factor (PDGF), which are involved in tumor-initiated angiogenesis. Carbonic anhydrase IX and signaling via the epidermal growth factor receptor (EGFR) are involved in tumor cell proliferation and are also up regulated by mutation in the VHL gene. The intracellular messenger pathways phosphoinositide 3-kinase (PI3K) and Raf/MEK/ERK act as convergence points for positive growth signaling; the Raf/MEK/ERK pathway is also implicated in apoptosis. Several agents in development target VEGF (bevacizumab), the VEGF receptor (PTK787, SU11248, VEGF-trap, and BAY 43-9006), the PDGF receptor (SU11248 and BAY 43-9006), or the EGF receptor (gefitinib, cetuximab, ABX-EGF, and erlotinib). The intracellular Raf/MEK/ERK signaling cascade has been targeted at either the level of Raf (BAY 43-9006, ISIS 5132) or MEK (CI-1040, PD184352 and ARRY-142886), and PI3K signaling is disrupted by CCI-779. WX-G250 targets the G250 antigen, and PS-341 disrupts the 26S proteasome mediating the degradation of intracellular proteins. Given that multiple pathways contribute to tumor growth, anti-tumor activity may be increased by agents targeting multiple pathways, or by combining agents to allow horizontal or vertical inhibition of multiple pathways.

[Management of urinary incontinence in the aging man]

The increasing prevalence and incidence of male urinary incontinence in senium-necessitate a specific as well as symptom and etiologically-oriented therapy. In addition to the conservative care with absorbent products, catheterization methods are available. Moreover, the problem can be successfully controlled in the majority of the patients through very specific drug and surgical therapeutic concepts.

Optimizing local anesthesia during 10-core biopsy of the prostate

OBJECTIVES

To examine, in a prospective, randomized study, the effect of different anesthetic techniques versus no anesthesia in a 10-core prostate biopsy. Reports thus far have shown a high variability in assessing the pain intensity of prostate biopsies and the effectiveness of anesthesia.

METHODS

Ultrasound-guided 10-core prostate biopsy was performed. Patients were prospectively randomized into four groups: no local anesthesia (group 1); anesthetic block of the prostatic plexus (group 2); local anesthesia onto the capsula of the apex (group 3); and a combination of the anesthesia used for groups 2 and 3 (group 4). The degree of pain was recorded using the visual analog scale/numeric analog scale (VAS/NAS) score.

RESULTS

The study included 187 patients. Results were assessed in 170 patients: 44 in group 1, 44 in group 2, 40 in group 3, and 42 in group 4. In group 1 (no anesthesia), 2 (4.5%) of 44 patients had no pain during biopsy (VAS/NAS = 0); the pain was mild (VAS/NAS of 1 to 4) in 38 (86.4%), moderate (VAS/NAS of 4 to 7) in 3 (6.8%), and severe (VAS/NAS of greater than 7) in 1 (2.3%) of 44 patients. The mean pain scores were 2.33 in group 1, 1.68 in group 2 (P = 0.05), 1.07 in group 3 (P <0.001), and 1.23 in group 4 (P <0.001). Pain caused by the local anesthesia itself was 0 in group 1, 1.52 in group 2 (P = 0.001), 1.05 in group 3 (P = 0.001), and 1.79 in group 4 (P = 0.001).

CONCLUSIONS

Local anesthesia significantly reduces pain. An injection onto the capsule at the apex was the most effective technique. It is technically easier to perform than an anesthetic block of the prostatic plexus and can be recommended.

Efficacy and tolerability of tolterodine in children with detrusor hyperreflexia

OBJECTIVES

To investigate the urodynamic effects and tolerability of the new antimuscarinic drug tolterodine in children with detrusor hyperreflexia.

METHODS

Twenty-two children (12 boys and 10 girls; age range 3 months to 15 years, mean age 5.7 years) with detrusor hyperreflexia resulting in maximum detrusor pressures exceeding 40 cm H(2)O during filling cystotonometry were enrolled to receive tolterodine tartrate (a total of 0.1 mg/kg orally daily, divided into two doses) either as a first-line therapy (n = 12, group 1) or replacing oxybutynin chloride therapy (n = 10, group 2). Within 3 months, all patients underwent urodynamic re-evaluation during ongoing tolterodine treatment.

RESULTS

In group 1, the mean maximum bladder capacity increased from 120.2 to 173.0 mL (+44%), the mean detrusor compliance increased from 8.7 to 13.5 mL/cm H(2)O (+55%), and the mean maximum detrusor pressures decreased from 70.1 to 37.9 cm H(2)O (-46%); the differences were significant (P < 0.001). In group 2, no differences in the urodynamic effects of oxybutynin versus tolterodine were noted. Only 1 patient experienced a transient and moderately adverse effect with tolterodine.

CONCLUSIONS

Although based on a limited number of subjects, these data indicate that in pediatric patients with detrusor hyperreflexia, tolterodine may be better tolerated than and equally effective as the standard drug oxybutynin chloride.

[Immunotherapy of metastatic renal cell carcinoma. Is clinical use justified in view of outcome, side effects and costs?]

The immunogenic potential of renal cell carcinoma and the resistance of its metastases against chemotherapy, radiation and hormonal treatment have led to the development of a great number and variety of different strategies, summarized under the term immunotherapy. Objective remissions can be expected in about 20-40% of patients. Another 30-40% show stable disease for a limited time, only occasionally for longer. Most results are from uncontrolled phase II studies. A cancer cure can usually not be expected, long-term remissions are rare (5%), and high remission rates are only observed in studies with strong patient selection. Some authors have reported a higher survival rate in patients treated with IL-2 or IFN. Survival of patients with objective remissions is significantly improved. A standard therapy cannot be defined. Even presuming an increased survival rate, the toxicity, which can lead to a dramatic reduction in quality of life, and the high costs have to be considered carefully. We think that in view of the lack of therapeutic alternatives, the improving efficacy, the potential survival benefit, the reduction of toxicity and the perspectives, immunotherapy is essential in the treatment of metastatic renal cell carcinoma. Its use should be confined to clinical studies.