Stellenwert der systemische Chemotherapie des Harnblasenkarzinoms

Almost half of the patients with muscle invasive disease already harbor at the time of their first diagnosis occult or distant metastases. Systemic disease has a poor prognosis with a long term survival of less than 10%. The administration of systemic chemotherapy aims to improve the course of locally advanced or metastatic disease.A survival benefit of 5% for patients receiving neoadjuvant and 9-11% using adjuvant chemotherapy is in the first scenario minimal, in the adjuvant setting to be noteworthy. The MVAC-schedule and the Gemcitabine/Cisplatin-combination chemotherapy have to be regarded as standard for induction chemotherapy. However, the 5-year survival rates with 15 or 13% are disappointing.Thus, prognostic factors gain importance since with their consideration significant differences in survival rates can be found. Hope is provided by a novel class of substances, the target-specific drugs, which selectively interfere with the cascade of steps involved in tumorigenesis.

[Chemotherapy of testicular cancer]

Platinum-based polychemotherapy has increased the cure rate in testicular cancer dramatically: at first, chemotherapy was mainly used in advanced disease. Recently it has also become common in low-stage disease, though other therapeutic options are equivalent. Risk factors might help to find the right decision. The success of treatment in patients with metastatic disease results from the combination of chemotherapy and secondary surgery. High-dose chemotherapy for patients with poor prognosis or recurrent disease is being evaluated in clinical trials. Concerning the success in these stages prognostic factors are of special importance. Patients with advanced-stage nonseminoma need residual tumor resection after chemotherapy if no complete remission could be achieved. The therapist should be aware of the indication for and schedule of chemotherapy, its side effects, and supportive care.

[Geriatric urology -- tumour diseases]

Due to demographic developments malignancies of urogenital origin will gain increasing importance. The urologist will face a growing group of patients with co-morbidities and functional disabilities as these neoplasms increase with age. Optimisation of peri-interventional management successfully reduces the risks of surgery. Integration of taxane-based cytostatic regimes achieves a prolongation of survival in hormone-refractory metastatic prostatic cancer. The introduction of gemcitabine in the management of malignancies of the bladder seems to have reduced toxicity while maintaining anti-tumour activity in comparison to MVAC. The role of haematopoetic growth factors remains to be defined in urologic malignancies - increasing dose intensity for better activity or reduction of toxicity. Individualisation of treatment requires early cooperation of the urologist, the oncologist and the geriatrician for an optimal outcome.

Do early injections of bulking agents following radical prostatectomy improve early continence?

Bulking agents belong to the treatment options of stress urinary incontinence in both genders for a long time, but early injection of bulking agents following radical prostatectomy to improve early continence is a new treatment modality and the results of the first years will be presented in this study. From 1996 to 2001, 55 incontinent patients, of whom 44 suffered from post-prostatectomy incontinence (PPI), have been treated by bulking agents in our clinic and evaluated later on, using a semistandardized questionnaire. Mean age was 65.5 years and the mean follow-up was 32 months. Of 44 patients with PPI, 29 suffered from incontinence of the third, 10 from incontinence of the second and 5 from incontinence of the first degree. We examined the influence of transurethral injection of bulking agents on direct postoperative continence (short-term results) and on continence at the time of follow-up (long-term results) (mean 32 month). An improved early continence (short-term result) was achieved in 30 patients. At follow-up, 19 patients were completely dry, 18 reported an improved continence. Especially the time of treatment, referring to radical prostatectomy, had a significant influence on treatment results with better results in the subgroup of 34 patients that have been treated early (mean 23 days) compared to 10 patients that received delayed treatment (mean 26 months) following radical prostatectomy. The preoperative degree of incontinence had a significant influence on short-term results, and not on long-term results. The amount of bulking material and the number of injections had no significant influence on short-term results, but repeated injections resulted in statistically worse long-term results. In summary, early transurethral injection of bulking agents is an effective and minimal invasive therapy option to improve early continence in patients with PPI. Time to improved continence due to training of the sphincter externus muscle cannot be shortened, but the quality of life during this time can be improved. In case of a severe lesion of the sphincteric muscle, continence cannot be improved for a longer period and the results are poor. In these cases, procedures like implantation of an artificial urinary sphincter may be required.

Limited survival of adult human testicular tissue as ectopic xenograft

BACKGROUND

Grafting of testicular tissue into immunodeficient mice has become an interesting and promising scientific tool for the generation of gametes and the study of testicular function. This technique might potentially be used to generate sperm from patients whose testes need to be removed or are destroyed due to therapeutic intervention or as a consequence of disease. Here we explore whether adult human testicular tissue from patients with different testicular pathologies survives as xenograft.

METHODS AND RESULTS

Testis tissue from adult patients with varying degrees of spermatogenesis was grafted into two strains of immunodeficient mice (severe combined immunodeficiency, Nu/Nu). Tissue with active spermatogenesis prior to grafting largely regressed. However, testicular tissue survival was better in cases where spermatogenesis was suppressed prior to grafting and occasionally spermatogonial stem cells survived. Cases with spermatogenic disruption were not corrected by the xenografting.

CONCLUSION

Superior survival of the germinal epithelium and spermatogonia when spermatogenesis was suppressed prior to grafting could provide a novel strategy for germline preservation in pre-pubertal cancer patients. This approach could also be valuable to study the early stages of human spermatogenesis.

[Therapy for infertile couples]

Therapy for infertile couples comprises gender-specific as well as couple-specific aspects. Diagnostic and therapeutic procedures focus on the causes of the infertility such as refertilization or epididymovasostomy on the one hand and assisted fertilization with extracted spermatozoa on the other. Using an interdisciplinary approach including urology, gynecology, reproductive medicine and human genetics, the treating physicians are able to fulfil the desire of infertile couples for a healthy child in many cases.

[Use of free dermal grafts in urology]

Plastic reconstructive surgery is of increasing importance in urology. The choice of the optimal material, for example dermal graft or musculocutaneous graft, is decisive for the operative success of each procedure. We present the technique, indications, innovations, and mutual fields with other operative disciplines.

[Reconstruction of female external genitalia]

Urologic surgery offers a broad spectrum of reconstructive procedures in males and females. A distinction should be made between constructive surgery as in cases of malformations or transsexualism and reconstructive procedures mainly after extensive tumor resections. Besides the description of different techniques in (re)construction of the external genitalia in females, the following article also addresses considerations concerning the indication for this kind of surgery and discusses some general aspects in plastic and reconstructive surgery.

Der Einsatz von Gleitmitteln in der Urologie

Lubricants are used for catheterization and/or endoscopic maneuvers. "The lubricant" should guarantee sufficient lubrification of the urinary tract, good visualization during endoscopy, and excellent local anesthesia. Additionally, asepsis or reliable control of the local bacterial flora of the urethra should be ensured. Modern lubricants fulfil these recommendations; in addition, they provide therapeutic opportunities for local therapy, for instance, of non-gonococcal urethritis. The latest results show that there are a few lubricants with antimicrobiotic influence on MRSA (methicillin-resistant Staphylococcus aureus), which is of great importance because of the steady increase in MRSA-dependent infections.

[Lymphadenectomy for testicular cancer. Diagnostic and prognostic significance as well as therapeutic benefit]

The rationale to perform retroperitoneal lymph node dissection (RPLND) in testicular cancer depends on the clinical stage and previous therapy. Thus, it can be performed either with diagnostic, prognostic, or therapeutic intention. In verified clinical stage I nonseminoma, RPLND provides one of three adjuvant options. To verify the clinical stage pathologically, surgery is done for diagnostic reasons, since CT scanning provides a false-negative staging in up to 30%. In higher stage lesions RPLND is a therapeutic procedure. The importance, however, of RPLND in clinical stage I nonseminoma is decreasing, since prognostic factors are available to stratify patients with either low or high risk for recurrence. Thus, these patients are selected for surveillance (low risk) or adjuvant chemotherapy (high risk). RPLND after chemotherapy is done for resection of residual tumor with a therapeutic intention. The histology of the residual mass is of prognostic importance and may help define further therapy. Resection of retroperitoneal metastases in patients with chemorefractory tumors is curative in about 25%.

[Geriatric assessment. Is it significantly helpful in selection of elderly tumour patients for a difficult therapy?]

With increasing life expectancy, a therapeutic decision raises the question of the primary goals to be aimed for. Is an absolute gain in age a goal equal to the preservation of an active life? While in younger patients the strategy followed by the patient and the doctor will usually be that of long-term survival, the decision making process for older patients with functional deficits is more challenging. Though functional deficits show a positive correlation with age, a causal relationship does not exist, which implies considerable inter-individual heterogeneity in the group of older patients. In particular, patients who have reached older ages "successfully" without any major limitations in their health should be considered for more intensive treatment strategies. At the same time, younger patients with relevant functional limitations and without any chance of improvement may not benefit from these interventions. The comprehensive geriatric assessment (CGA) offers the opportunity to describe and classify these deficits systematically. It therefore has a key role in the individual decision making process.

Systematic Development of a Guideline for Early Detection of Prostate Cancer: The German Way in the Evidence Gap

OBJECTIVE

To develop an evidence-based guideline, helping physcians make prudent decisions about diagnostic care for men wishing to undergo examination for early detection of prostate cancer.

METHODS

A guideline development group, comprised of twenty healthcare professionals, including urologists, clinical chemists, pathologists, geriatricians, epidemiologists, technicians and a member of a patient self-help group, systematically gathered, evaluated, and discussed the most recent research available on early detection of prostate cancer. Nominal group technique (NGT) was employed to facilitate the decision-making process.

RESULTS

The NGT was sufficient to find a consensus among different medical disciplines in a timely fashion. A standardized guideline, containing a short version for physicians and a standardized patient information booklet, for nation-wide use was developed.

CONCLUSIONS

Population-based screening is not favoured, instead information should be given to men in their 50-70s, to enable shared decision-making between physician and patient for or against PSA-based early detection of prostate cancer.

[Therapy of advanced penis carcinoma]

Skin infiltration and locoregional lymph node extension in metastatic penile cancer leads to destruction in the inguinal and perineal region. Efficacy of systemic polychemotherapy based on cisplatin, methotrexate, and bleomycin (CMB scheme) is limited with an objective remission rate up to 30% only. The obligatorily superinfected defects require tension-free and extended coverage with immediate myocutaneous flaps after surgical resection. Pedicle flaps, consisting of skin, fascia, muscle, and the supplying vessels, are used to cover the post-resection defects. In the field of surgical uro-oncology the following myocutaneous flaps listed with the supplying vessels have proved themselves: M. tensor fasciae latae flap (A. circumflexa femoris lateralis), M. rectus abdominis flap (A. epigastrica inferior), M. gluteus maximus flap (A. glutea inferior). Data concerning a prospective study for neoadjuvant chemotherapy with CMB followed by surgical tumor resection with immediate myocutaneous flap reconstruction are presented. In 15 patients (median age: 69.7 years) suffering from squamous cell carcinoma of the penis (Tx, N3, M1 cutis), a surgical excision of the tumor was performed after neoadjuvant chemotherapy (median:2.4 cycles) and antibiotic pretreatment. All patients received coverage of the femoral vessels with a musculus sartorius transfer on both sides. An extended (up to 45x30 cm) tension-free coverage of groin defects was performed in two patients with a unilateral M. tensor fasciae latae flap (TFL) and in eight patients with a bilateral TFL. One patient received a M. gluteus maximus flap (GMFL) on both sides, three patients were treated with a combination of M. rectus abdominis flap (RFL) and TFL, and one patient received a combination of two TFL, one GMFL as well as one RFL. Of 31 myocutaneous pedicle flaps, 2 developed distant necrosis of the flap, in which one GMFL and one TFL were affected. No complete necrosis of the pedicle flap occurred. Primary wound healing was found in 29 of 31 myocutaneous flaps. The covering of groin defects by the use of myocutaneous flaps, such as the M. tensor fasciae latae, M. rectus abdominis, and M. gluteus maximus flap, is a method of first choice in the primary treatment of even bacterially contaminated wounds or after radiation therapy. The techniques of pedicle flaps are comparably applied in oncology and traumatology.

ABSORPTION OF INTRAVESICALLY APPLIED DRUGS: COMPARISON OF NORMAL AND ILEAL AUGMENTED RABBIT BLADDER

PURPOSE

Drug absorption within urinary diversions has been reported to cause prolonged and higher grade toxicity. Therefore, continuous urine drainage has been recommended during chemotherapy in patients with continent urinary diversion. We developed an animal model in which to examine the significance of drug absorption in normal rabbit bladders compared with ileal augmented bladders.

MATERIALS AND METHODS

Ten rabbits with ileal bladder augmentation and 5 control animals were used for absorption studies with methotrexate and ofloxacin. One, 4 and 12 months after surgery the rabbits received an intravesical instillation of either drug. During 2 hours blood samples were drawn. To avoid overfilling the bladder by urine it was emptied after 30, 60, 90 and 120 minutes, and refilled with fresh solution to yield a relatively constant drug amount. After 12 months the animals were sacrificed. Area of the native bladder wall and of the intestinal segment was measured to allow the correction of absorbed drug amounts per surface area. Moreover, the median villous heights of native and augmented ileum were compared histologically. Serum levels of methotrexate and ofloxacin were determined by high performance liquid chromatography.

RESULTS

The maximum serum concentration of the 2 drugs was typically seen after 60 to 120 minutes. During the 1-year period peak serum concentrations of ofloxacin remained consistently higher in ileal augmented than in control rabbits, although this did not achieve statistical significance at all instillation time points. For methotrexate a statistically significant difference was not shown for either time point. When absorption was corrected for total bladder surface area, the enhancement of ofloxacin absorption by ileal augmentation weakened and attained statistical significance only at the 1-month time point. Histological examinations after 12 months showed that augmented intestinal mucosa had a significantly smaller villous height than native ileum.

CONCLUSIONS

Our data demonstrate that bladder surface is the most important factor for increased absorption but time dependent histological changes of the integrated intestinal mucosa also influence absorption. There is a broad interindividual discrepancy. Therefore, general rules in patients with urinary diversion may not be justified.

[Testosterone and the prostate]

Testosterone has a distinct role in benign and malignant diseases of the prostate. Therefore, knowledge about the physiological interactions between testosterone and the prostate and the special circumstances under testosterone substitution are of great impact for urologists.PSA value and prostate volume do not show significant changes under testosterone substitution therapy. Even if there are no long-term studies in men under substitution due to decreased testosterone, the therapy seems to be safe under regular control of the prostate with PSA and sonography, and the risk for prostate carcinoma is not increased. In hypogonadal men with high-grade PIN under testosterone substitution, 1 in 20 cases with suspicious rectal examination exhibited a carcinoma; the PSA values did not show a difference between men with or without PIN.Nevertheless, it remains unclear whether men after successful radical prostatectomy should receive testosterone substitution.

[Stinging nettle root extract (Bazoton-uno) in long term treatment of benign prostatic syndrome (BPS). Results of a randomized, double-blind, placebo controlled multicenter study after 12 months]

Phytotherapy of BPS has a long tradition in Germany; nevertheless, data referring to single phytotherapeutic agents are rare. We therefore performed a randomized, double-blind, placebo-controlled multicenter study for 1 year with Bazoton uno (459 mg dry extract of stinging nettle roots) with 246 patients. The IPSS decreased on average from 18.7+/-0.3 to 13.0+/-0.5 with a statistically significant difference compared to placebo (18.5+/-0.3 to 13.8+/-0.5; p=0.0233). The median Q(max) increased by 3.0+/-0.4 ml/s in comparison to 2.9+/-0.4 ml/s (placebo), thus not statistically significantly different, as well as the median volume of residual urine, which changed from 35.5+/-3.4 ml before therapy to 20.0+/-2.8 ml and from 40.0+/-4.0 ml to 21.0+/-2.9 ml under placebo application. The number of adverse events (29/38) as well as urinary infections etc. (3/10 events) was smaller under Bazoton uno therapy compared to placebo. Treatment with Bazoton uno can therefore be considered a safe therapeutic option for BPS, especially for reducing irritative symptoms and BPS-associated complications due to the postulated antiphlogistic and antiproliferative effects of the stinging nettle extract. A strong increase of Q(max) or reduction of residual urine are not to be expected.

Pr�vention des Harnblasenkarzinoms

Bladder cancer has a high incidence; therefore, the prevention of bladder cancer is useful. Each year 15,000 patients suffer from bladder cancer in Germany. These tumors are chemically induced and the development of bladder cancer is determined by the carcinogen and the time of exposure i.e., exposition time. Development of bladder cancer also depends on the patient's age. In patients younger than 45 years bladder cancer is a rare disease. The incidence of bladder cancer is 3 of 100,000 in males at the age of 45-50 years and it increases in the cohort of males older than 80 years to 200 of 100,000. Bladder cancer is a serious disease. The annual loss of life related to bladder cancer is 64,700 life years in Germany alone! Identification of carcinogens makes a preventative approach possible and leads to the detection of occupationally endangered people. Bladder cancer carcinogens include aromatic amines, medicaments (chlornaphazin, phenacetin, and cyclophosphamide), cigarette consumption, chronic infection of the lower urinary tract, radiation therapy of the pelvis, bilharciosis, Balkan nephropathy, and chronic interstitial nephritis.

[The medication-induced dysfunction of the urinary bladder]

Bladder dysfunction can result from pathological changes in the bladder itself, of its central neurological regulation, (BPS), or of non-urological diseases such as diabetes or heart failure. Medication-induced bladder dysfunction can mostly be treated by simple changes in the pharmacological therapy. Bladder dysfunction can be induced pharmacologically by activating or inhibitory influences on adrenergic, sympathetic, beta-receptor-induced relaxation of the detrusor, alpha-receptor-induced contraction of the bladder neck, or cholinergic, parasympathetic, muscarinic receptor-induced contraction of the detrusor. Diuretics can increase urine production, thus possibly leading to incontinence. If incontinence occurs in patients, treatment should be stopped if possible and additional pharmacological therapy should not be started before medication-induced bladder dysfunction is excluded.

Inhalative Immuntherapie beim pulmonal metastasierten Nierenzellkarzinom

Studies on immunotherapy with inhaled interleukin-2 (IL-2) for the treatment of pulmonary metastases in renal cell carcinoma patients have indicated objective response rates of 11%. The aim of the present study was to evaluate efficacy, toxicity, and quality of life during inhaled immunotherapy with IL-2. Patients with pulmonary metastases of renal cell carcinoma were treated with interferon-alpha (IFN-alpha) 3 x 10(6) IU/m(2) s.c. on days 1, 3, and 5 and inhaled twice a day 9 x 10(6) IU IL-2 on days 1-5. Treatment continued for 4 weeks and after a 2-week rest a second cycle was given. Patients who responded received two additional cycles. Quality of life was assessed according a self-administered quality of life questionnaire (QLQ-C30) before, during, and after therapy. Of 23 treated patients, 21 could be evaluated concerning response rate and toxicity [16 men, 5 women; median age: 60 years (38-72 years)]. Sixteen patients had pulmonary metastases only and five patients additionally had bone or liver metastasis or local recurrence. One patient (5%) developed a partial remission for 4 months and ten patients (47.5%) showed a stable disease for a median time of 6 months (2-24 months). The median follow-up was 9 months (3-26 months). Ten patients (47.5%) developed progressive disease. Maximal toxicity was mild and grade III-IV toxicity (WHO) was not observed. The patients' quality of life did not change significantly at any time during therapy. Inhaled immunotherapy is a treatment option with little toxicity, but achieved only a few objective responses. Whether or not it influences overall survival could not be answered in this study.

Perioperative Chemotherapy in Advanced Bladder Cancer - Part II: Adjuvant Treatment

Despite radical cystectomy, 40% of the patients with locally advanced disease and more than 80% of the patients with lymphatic metastases die tumor related. This provides the rationale for additional effective systemic therapy following surgery. In addition, previous surgery and consecutive histopathological or cell-based evaluation offers the advantage to expose only those patients to adjuvant systemic chemotherapy, who belong to a defined high-risk group. Regional lymph node metastases range from less than 10% in T1 to nearly 33% in T3/T4 lesions. Therefore, the extend of the lymph node dissection as an integral part of the surgical treatment gains importance. As pathological assessment of an adequate number of lymph nodes increases the likelihood of proper staging and decisions on further therapy depend on accurate staging, a standardization of lymphadenectomy is desirable. This paper provides an overview on the current concepts of the use of adjuvant systemic chemotherapy in the treatment of advanced urothelial cancer.

[Complementary and alternative medicine in urologic oncology]

The great majority of phytotherapeutic, homeopathic and anthroposophical medicines are subject to the regulations in their respective field of application, implying a simple licensing process. In contrast with conventional medications in the area of oncology, some unconventional agents are given in observation studies without the prior testing of quality, side effects and efficacy that is normal in oncology. Unconventional therapeutics cannot be considered equivalent to placebo preparations. Since they may have an immunomodulatory action, one cannot exclude possible long-term adverse effects, including progression of tumors. To date there is no clear indication for routine use of unconventional therapeutic agents in urological oncology. A scientific evaluation according to the criteria of evidence-based medicine is required. This article presents proven results of treatment with unconventional medicines in urooncology against the background of the respective spectrum of methods.

[Surgical treatment of advanced baldder carcinoma]

Radical cystectomy is the treatment of choice for patients with muscle-invasive or locally advanced bladder carcinoma. Alternative treatment options are simultaneous radiochemotherapy following transurethral tumor resection or percutaneous definitive radiotherapy. To prevent early tumor progression, treatment decision should be made within 6 months after initial diagnosis. Extended lymphadenectomy seems to have an impact on progression-free survival, as determined in retrospective analyses. Excellent long-term results exist for urinary diversion using ileal neobladder or ureter bowel implantation into an augmented colon sigmoideum segment. Similarly good results are reported for female patients. Quality of life (QoL) in correlation to type of urinary diversion is under discussion. Ileal conduit seems to be of advantage for QoL especially in elderly patients. Surgical removal of metastases is controversially discussed, especially in those patients without tumor-related symptoms. An age of more than 70 years seems to be no exclusion criterion for radical cystectomy. Treatment morbidity and mortality are similar to those of younger patients. Long-term results confirm the excellent results of orthotopic bladder replacement.

Chemotherapie im Alter

The incidence of cancer is age-related and increases rapidly. The age itself is not a contraindication for chemotherapy. Essential is the evaluation of comorbidity and the functional status of the elderly. Due to the physiologic decline in renal function and hepatic drug metabolism with age, the doses of chemotherapeutic agents should be adapted in the elderly. The elderly remain underrepresented in clinical trials. In the absence of comprehensive data on treatment in the elderly, it can be expected that response rates and toxicity to chemotherapy will be the same as in younger patients.

Perioperative chemotherapy in advanced bladder cancer: part I. Neoadjuvant treatment

Despite local tumor control, patients with locally advanced bladder cancer or lymphogenic metastasized urothelial carcinoma are at risk for systemic progress. Radical cystectomy is the gold standard treatment for muscle-invasive bladder tumors. Pelvic lymphadenectomy remains an integral part of the surgical treatment. However, the extent of the lymph node dissection depends on its diagnostic or curative intent and is more controversial. In addition, further treatment options such as systemic chemotherapy or combined radio-chemotherapy are needed to improve the outcome of locally advanced or metastasized disease. Therefore, administration of additional therapy to surgical treatment is intensively studied. The application of the neoadjuvant concept as well as the definite role of the adjuvant chemotherapy currently are contentious topics and subjects of meta-analyses and prospective randomized trials. In addition, bladder preservation as part of a multimodality treatment is still discussed as an option for selected patients unsuitable for radical cystectomy. This article gives an overview on the current concepts of the use of neoadjuvant systemic chemotherapy in the treatment of advanced urothelial cancer.

Phase II study of repeated single 24-hour infusion of low-dose 5-fluorouracil for palliation in symptomatic hormone-refractory prostate cancer

BACKGROUND

To assess the efficacy and toxicity of repeated single 24-hour infusion of low-dose 5-fluorouracil for symptomatic hormone-refractory prostate cancer using relevant endpoints of palliation and biological response.

PATIENTS AND METHODS

25 patients with histologically confirmed prostatic adenocarcinoma and symptomatic progressive disease despite one or several hormonal treatments and chemotherapy were included in the study. Treatment consisted of a single 24-hour infusion of 500 mg/m(2) 5-fluorouracil (5-FU) to be repeated on day 21. This regimen was continued until either progression or serious toxicity occurred. Response was assessed by serial measurements of serum prostate-specific antigen (PSA) as well as by health-related quality-of-life instruments (EORTC QLQ-C30 and McGill-Melzack Present Pain Intensity Scale) every 3 weeks. In 10 patients with bidimensionally measurable metastases, objective responses were assessed every 3 months.

RESULTS

A mean number of four courses of repeated single 24-hour infusion of 5-FU was administered (range 2-6). Toxicity was absent or mild, and no patient had to be withdrawn from therapy. All patients required analgesics prior to treatment and only 3 patients experienced a significant reduction in pain for 9 weeks, the remaining patients experienced no deterioration for a mean duration of 12 weeks (6-18 weeks). Five patients (20%) demonstrated a biological response of a 50% or greater decrease in PSA from baseline, including 2 (12%) with a 75% or greater decline for 10 weeks (range 6-16 weeks). One partial remission was observed among 10 patients with measurable lesions lasting 12 weeks; 4 patients had stable disease with a mean duration of 12 weeks. Mean survival time from the onset of treatment with 5-FU was 7 months (2-12 months).

CONCLUSIONS

Though less toxic than other 5-FU regimens, repeated single low-dose 24-hour infusion is of no significant benefit in patients with symptomatic hormone-refractory prostate cancer.

Treatment of penile curvature--how to combine the advantages of simple plication and the Nesbit-procedure by superficial excision of the tunica albuginea

Different treatment options for penile curvature exist, such as the Nesbit procedure with complete excision of the tunica albuginea or the simple plication. We prefer a modification with only superficial excision, not opening the corpora cavernosa. From January 1997 to June 2000, 68 patients were treated surgically due to penile curvature. Data was obtained from 48 patients by telephone interview. The mean penile deviation was 46 degrees. Excision of the tunica was performed only superficially and non-absorbable inverted sutures were used. The mean follow-up time in this study was 25 months. A total of 36 (75%) patients were satisfied postoperatively, 12 were unsatisfied. Eleven (23%) patients described a complete straightening, 37 (77%) a rest-curvature of 5-50 degrees (mean 14 degrees ) and 21 (44%) described a shortening of 0.5-5 cm (mean 1.2 cm). Six patients reported a recurrence. No new erectile dysfunction occurred. Superficial excision of the tunica albuginea offers the advantage of tissue-contraction due to scarring without destroying the integrity of the corpora, leading in combination with non-absorbable inverted sutures to good functional and cosmetic results.

[Chronic pain syndrome in uorology]

Chronic pain of the genital region remains a therapeutic challenge. Among men, symptoms are mainly related to the prostate, bladder and scrotal organs, and among women to the bladder and vagina. Only some of the cases demonstrate pathologic changes of the symptomatic organs requiring specific treatment. Among pain medications, peripheral analgesics are the most suitable. In the case of chronic pain, which can be classified according to Gerbershagen, a psychosomatic origin also has to be considered and needs to be evaluated. Analgesics are of minor importance in the treatment of psychosomatic syndromes but tricyclic antidepressants or anticonvulsants may be helpful. Relaxation techniques also need to be considered.

[Occurrence, diagnostics and therapeutic management of hydronephrosis in pediatric patients in Germany]

As urinary tract obstruction in children may impair renal function, the early detection and evaluation of the degree of obstruction using adequate diagnostic tools is necessary for the choice of the optimal therapeutic procedure. This study describes diagnostic and therapeutic standards in relation to the quality of management of pediatric hydronephrosis in Germany in the first 6 months of the year 2000. In our study 407 of 711 (57.2%) children with a hydronephrotic condition were detected by routine ultrasound. This, and the fact that 25% of the patients, who were prenatally detected, had a diagnosis of vesicoureteral reflux, underlines the importance of this routine procedure. Our study illustrates the panel of diagnostic and therapeutic procedures used in the management of pediatric hydronephrosis in Germany.

[European Association of Urology guidelines on urinary and male genital tract infections]

Today, the classical bacteria that cause venereal diseases, e.g. gonorrhea, syphilis, chancroid and inguinal granuloma, only account for a small proportion of all known sexually transmitted diseases (STDs). Other bacteria and viruses as well as yeasts, protozoa and epizoa must also be regarded as causative organisms of STD. Taken together, all sexually transmitted infections comprise more than 30 relevant STD pathogens. However, not all pathogens that can be sexually transmitted manifest diseases in the genitals and not all infections of the genitals are exclusively sexually transmitted. Concise information and tables summarising the diagnostic and therapeutic management of STDs in the field of urology allow a synoptic overview, and are in agreement with the recent international guidelines of other specialist areas. Special considerations (i.e. HIV infection, pregnancy, infants, allergy) and recommended regimens are presented.

Surgical treatment of disseminated peritoneal metastases from urological cancer: results from a prospective study

OBJECTIVE

To report a prospective phase II study of patients with disseminated peritoneal carcinomatosis and symptomatic disease, in whom the peritoneal metastases were resected.

PATIENTS AND METHODS

From 1995 to 1999, 32 patients (20 men and 12 women, median age 56 years, range 32-75) with peritoneal carcinomatosis were enrolled in the trial. Pain and ascites were determined according to the National Cancer Institute score/criteria, and performance scored according to the World Health Organisation criteria.

RESULTS

All patients had intraperitoneal disseminated malignancies with clinically evident ascites, and presented with abdominal pain. The median (range) operative duration was 2.9 (1-5.5) h and the hospital stay 25 (10-44) days, with no deaths at 30 days. The ascites was completely cured in 25 of the 32 patients, pain relieved in 28 and the performance score improved in 25. The median survival time was 1 year; the 1- and 2-year survival rates were 45% and 38%, respectively. Patients with residual metastases after incomplete resection had a significantly worse prognosis, but the prognosis was significantly better in those with a low tumour burden.

CONCLUSIONS

Peritoneal carcinomatosis is treatable; radical peritonectomy improves the performance score in selected patients with cancer-related ascites and/or pain, and is now the standard approach in the authors' Cancer Centre.

[Tumors in the elderly]

The prevalence and incidence of cancer are age related; increased longevity thus increases the number of elderly patients with cancer. Only a few data suggest that en bloc radical cystectomy in patients with bladder cancer and radical prostatectomy in patients with prostate cancer can be safely performed on properly selected elderly patients (aged 70 years or older) with results comparable to those for younger patients. Due to the physiologic decline in renal function and hepatic drug metabolism in old age, chemotherapeutic agents show increasing toxicity in the elderly. The elderly remain underrepresented in clinical trials. In the absence of comprehensive data on treatment in the elderly, the belief persists that the elderly derive less benefit and suffer greater toxic effects from chemotherapy than younger patients.

[Urothelial carcinoma. Role of G-protein coupled receptors in cell movement and proliferation]

To develop new therapeutic strategies we examined the expression and signaltransduction of G protein-coupled receptors in a human transitional cell carcinoma cell line. The receptors for lysophosphatidic acid (LPA) and thrombin potently stimulate cell migration. Pretreatment with PTX completely inhibited cell motility induced by LPA. In the model of chemically induced bladder carcinoma in rats the effects of intravesical instillation of PTX or phosphate buffered saline was examined. The incidence of G2-G3 cells in cytology was significantly reduced in rats treated with PTX. To ascertain the side effects of intravesical instillation of PTX a Phase I study was initiated. 15 patients were instilled with PTX at 5 dose levels (14-72 micrograms/100 ml) 3 times a week. Instillation of PTX up to 72 micrograms was without local or systemic side effects. PTX is a substance which potently inhibits tumor cell motility and progression. Intravesical treatment was well tolerated and therefore, the influence of PTX on local tumor should be evaluated in a Phase II study.

Local antiseptic therapy for non-gonococcal urethritis: phase II study with Instillagel

Non-gonococcal urethritis (NGU) is conventionally treated with oral antibiotics. With this Phase II study, we investigated the action of a locally disinfecting substance, Instillagel, in symptomatic NGU. Instillation treatment was performed twice daily to 32 male patients with symptomatic NGU. To evaluate the therapeutic outcome, a smear was taken from the urethra and an urine examination was performed at baseline as well as at 5 and 8 days after the start of the treatment. Pain and micturition symptoms were determined by a questionnaire with analog scales taken before and after therapy. A pre/post comparison of the urethral smears of the patients with symptomatic NGU showed a significant difference (P < 0.0001). The microbial count in the urine did not show a significant difference. The symptoms micturition (P<0.0001) and pain in the urethra (P<0.0001) were significantly improved. This Phase II study confirmed that local antiseptic treatment of NGU can offer an alternative to systemic antibiotic treatment.

[Evaluation of the complementary drug Factor AF2 as a supportive agent in management of advanced urothelial carcinoma. Prospective randomized multicenter study]

This is a prospective randomized multicenter trial for evaluation of the biological response modifier Factor AF2 in advanced urothelial cancer treated with chemotherapy. Main aim of the study was the analysis of supportive effects. Additionally patients were examined with regard to tumor response, time to progression and survival. 106 patients with advanced urothelial cancer received chemotherapy with cisplatin and methotrexate. They were randomized for additional Factor AF2 (500 mg i.v., given at days 0-3, 7-10 and 11-14). Myelotoxicity was more common and severe in the group without Factor AF2 reaching statistical significance. Gastrointestinal side effects occurred in both groups, though grade III to IV toxicity was more common without Factor AF2. Overall remission rate was 38%, median survival 33 weeks, mean time to progression 20 weeks. There was no significant difference between the two groups with or without Factor AF2.

[Locally advanced or metastatic bladder carcinoma. Current aspects of therapy]

The prognostic factors for infiltrating tumors established by the TNM system in 1997 include: Depth of infiltration, degree of differentiation, status of lymph nodes distant metastases. Of the additional factors investigated, only tumor size and hydronephrosis appear to be of prognostic significance. In the scope of molecular markers, the loss of expression of the epithelial cell-cell adhesion molecule E-cadherin signals an unfavorable clinical course. In cases of carcinoma of the urinary bladder without metastases (T2-4,N0,M0), radical cystectomy is the therapy of choice. A preceding neoadjuvant systemic regimen of chemotherapy with three cycles of M-VAC (methotrexate, vinblastine, adriamycin, cisplatin) significantly improves the survival rate. In patients with locally advanced urinary bladder carcinoma, however, adjuvant systemic chemotherapy with M-VAC after cystectomy and lymphadenectomy offers no advantages for survival. Quality of life in patients with metastatic bladder cancer disease is improved by new cytotoxic drugs, i.e. gemcitabine or taxanes.

[Treatment of metastases of urothelial carcinoma. Results of a prospective study of metastases surgery]

We initiated a prospective phase II trial to assess the outcome of complete surgical removal of metastases from bladder cancer with regard to survival and quality of life. Between 1995 and 1999, 70 patients (52 males, 18 females) with a median age of 64 years (range: 30-88 years) were treated with surgical complete resection of bladder cancer metastases. Patients with asymptomatic (n = 19) and symptomatic (n = 51) secondary metastases from bladder cancer refractory to methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) therapy were included. We removed secondary metastases in lymph nodes (63%), peritoneum (10%), skin (3%), bone (3%), lung (15%), and liver (6%) and measured survival and performance scores. The median survival time was 7 months. With a 1-year survival rate of 30% and a 2-year survival rate of 19%, the prognosis is unfavorable independent from the site of metastasis. However, 83% (42 of 51) of the patients with symptomatic secondary metastases did benefit from surgery regarding quality of life, e.g., performance score, and we assessed an improvement in the WHO performance score from 3.3 to 2.1 (p = 0.005). Surgical removal of metastases from bladder cancer refractory to systemic therapy has an impact on quality of life limited to patients with symptomatic disease.

Metachronous contralateral germ cell tumor 7 years after management of testicular intraepithelial neoplasia by chemotherapy and multiple control biopsies

We report about a metachronous germ cell tumor 7 years after chemotherapy of advanced testicular cancer and contralateral testicular intraepithelial neoplasia (TIN). Chemotherapy can not safely eradicate TIN. The safest treatment for TIN remains low dose radiation.

[Hormone therapy of locally advanced and metastatic prostate carcinoma]

Hormonal treatment is a androgenoprive therapy. Adjuvant treatment after radical prostatectomy or radiotherapy seems to have no survival benefit. Neoadjuvant hormonal treatment before local therapy has no proven survival benefit. Hormonal treatment in metastatic disease can be initiated immediately, deferred or intermittent. Androgen-deprivation is performed by castration or LHRH-analoga and/or anti-androgens. Maximal androgen-deprivation has significant more side effect and is of only limited survival bebefit for a subgroup of patients. The onset of hormonal treatment is under discussion. An increase of PSA (> 25 ng/ml) and/or occurrence of symptoms is an indication for hormonal treatment. Intermittent androgen-deprivation is under investigation as a new concept.