[Verumontanum mucosal hyperplasia as a differential diagnosis of a local recurrence following radical prostatectomy]

Verumontanum mucosal gland hyperplasia (VMGH) is a benign microacinar proliferative lesion, which occurs exclusively in the verumontanum and the posterior urethra and is one of the lesions that may be confused with a low-risk adenocarcinoma of the prostate gland.We present the case of a 72-year-old male patient who underwent radical prostatectomy due to an adenocarcinoma of the prostate gland (pT2c pN0 cM0 R0, Gleason Score: 3 + 3 = 6). Five years after the operation, we sonographically detected a 3x2 cm large tumour in the prostate bed. While our first assumption was a PSA-negative local recurrence following radical prostatectomy, a comprehensive histological examination along with the clinical evaluation led us to the diagnosis of a VMGH. VMGH is a less well-known differential diagnosis of PSA-negative local recurrence following radical prostatectomy, whose clinical manifestation should be presented.

[Complications and their management after urinary diversion]

BACKGROUND

Bladder cancer is a common disease. It is predicted that 11,900 men and 4,500 women in Germany will be diagnosed with invasive bladder cancer in 2014. The cystectomy, which is standard treatment in muscle-invasive bladder cancer, requires urinary diversion.

PURPOSE

The goal of this article is to present the complications associated with urinary diversions and their management.

METHODS

Based on a selective literature search in PubMed and our own clinical experience, the options for urinary diversion and their management are discussed.

RESULTS

In patients treated with curative intent, orthotopic bladder replacement is preferred. In patients with palliative intent, incontinent cutaneous urinary diversion is commonly used. The present work shows the variety of early and late complications, peri-/postoperative mortality, and the management of these patients.

CONCLUSION

After cystectomy, various methods for urinary diversion are available, which can be used in curative and/or palliative intent. Crucial to the success and the long-term satisfaction of the patients is selection of the right urinary diversion method.

[Squamous cell lesions of the urinary bladder]

BACKGROUND

Squamous cell carcinoma (SCC) and transitional carcinoma with squamous differentiation (SCC/TCC) are rare in western countries. Chronic inflammation and irritation of the urothelium are common risk factors for the development of SCC and TCC/SCC. Tumour biology of squamous cell cancer and precancerous squamous lesions is different from transitional cell cancer (TCC). Recent advances in molecular analysis of benign and malignant squamous cell lesions indicate that they are closely associated and might lead to improved bladder cancer subclassification in the future.

AIM

At present, the clinical management and therapy of SCC remains challenging, as scientific evidence based on prospective clinical trials is not available. We performed an analysis of available literature on natural history, treatment, and prognosis of SCC, SCC/TCC and metaplastic lesions. Furthermore, recent findings in molecular cancer biology are discussed with a focus on their relevance for SCC carcinogenesis.

[Varicocele in adolescents]

Testicular varicocele is present in 15 % of adolescent boys. The very impact of this pathology and who will be at risk of developing into infertility remains unclear. Research on the pathophysiology, results of surgical or radiological interventions and potential predictors for long-term impairment of spermatogenesis and thus fertility is still ongoing. Indications for treatment are mainly based on differences in testicular volumes as semen parameters are most often not available; however, whether testicular volume is a valuable prognostic parameter for later fertility remains questionable. Approximately 50 % of adolescent patients with varicocele experience spontaneous increase of testicular volume without any intervention.

[Contralateral inguinal metastasis from testicular seminoma]

We report the case of a 42-year-old patient with contralateral inguinal seminoma metastasis. He had a history of prior bilateral open inguinal hernia repair and scrotal vasectomy. Staging CT revealed no further lymphoma or organ metastases. After discussion of adjuvant treatment options and contacting a referral centre for testicular cancer, adjuvant treatment was performed with 3 cycles of cisplatin, etoposide and ifosfamide. The development of the contralateral inguinal metastasis is most likely caused by the prior inguinal and scrotal surgery, whereas a primary atypical retrograde metastatic route can't be ruled out. Physical examination of the inguinal lymph nodes should be performed in all patients with testicular cancer and prior inguinal and scrotal surgery.

[Phyllodes tumour of the seminal vesicle - case report of a rare tumour entity]

Neoplasms of the seminal vesicles are rare. Here we report on a patient with a low-grade phyllodes tumour of the seminal vesicle. The patient was admitted to our hospital with a tumour in the excavatio rectovesicalis diagnosed by CT scan. He had no symptoms. For further diagnosis we took transrectal ultrasound-guided biopsies, the histopathological examination showed no malignant features. One month later a follow-up CT scan demonstrated a significant enlargement of the tumour. Therefore we decided to perform a surgical exploration. During surgery we found a partially necrotic mass involving the prostate, the urinary bladder and the rectum. Both radical cystoprostatectomy with ileal conduit and anterior resection of the rectum with colostomy were necessary. Histologically the specimen showed a low-grade phyllodes tumour of the left seminal vesicle. One year after surgery the follow-up was completely normal without any residual or recurrent tumour. Frequency, histology, diagnostic investigations, therapy and prognosis of this rare tumour entity are discussed with respect to the actual literature.

Descending nerve-sparing radical prostatectomy--results and consequences

Nerve-sparing radical prostatectomy is the therapy of choice in selected prostate cancer patients. In an internal quality control including a questionnaire, our nerve-sparing radical prostatectomies have been analysed for oncological and functional results as well as patient satisfaction. 171 consecutive nerve sparing radical prostatectomies have been analysed, 123 bilateral, 48 unilateral. The median follow-up was 26 (2-56) months. The operations were performed by 5 surgeons. In 27% the T-category and in 12% the Gleason score had been understaged preoperatively, 9% had positive margins and in 4% lymph nodes were positive. 99% of the patients stated that they would again prefer the operation as treatment of first choice. 95% were satisfied with their postoperative situation. 53% of the patients had erections sufficient for sexual intercourse following the bilateral, 25% following the unilateral nerve-sparing procedure. The time until recurrence of erections was 1 month in 42%, 6 months in 90% and 12 months in 100% of the potent men. 90% of all patients within the observation period are fully continent, 10% of the patients need more than 1 pad. The intersurgeon variability is 77-98% for continence and 25-60% for potency. Patient satisfaction, oncological and functional results are good. The understaging rate suggests the necessity for better patient selection including re-biopsy and reference histology. 27% would have been undertreated by brachytherapy as alternative treatment. Intensive surgeon teaching is mandatory.

[Bronchopulmonary sequestration presenting with flank pain]

INTRODUCTION

Flank pain is a classical symptom in urological patients and can have various causes. We now present a case in which we were able to diagnose retroperitoneal bronchial sequestration as a very rare cause of flank pain.

CASE REPORT

In the work-up of left flank pain in a 37-year-old woman, a suprarenal mass, about 5 cm in diameter, was diagnosed in a CT scan. The patient underwent surgery and a pulmonary sequestration was identified histologically. This very rare differential diagnosis of suprarenal masses belongs to pulmonary malformations and normally is an asymptomatic accidental finding. Up to now, only few reports are documented in literature where pulmonary sequestration showed symptoms like flank pain. In this case, the pain seems to be due to mucus retention in the sequester. The literature on this disease is presented here.

[Postoperative problems and after-care in post-radical-prostatectomy patients]

Essential components of tumor follow-up in prostate cancer patients are considered to be the determination of PSA in combination with digital rectal examination, and abdominal together with transurethral ultrasonography. Depending upon the symptoms presenting, additional specialist urological examinations, such as urine flow measurement and cystoscopy may be indicated. The follow-up should be carried out every three months in the first postoperative year, every 6 months in the following years, and annually thereafter.

EAU guidelines on renal transplantation

OBJECTIVES

To produce a guidelines text, on behalf of the European Association of Urology, providing insights in the issues surrounding renal transplantation.

METHOD

A group of international experts in renal transplantation carried out a non-structured literature review on available medical databases and urological literature.

RESULT

A guideline text is presented providing an overview of key issues involved in the patients' management such as assessment of donors, pre-transplant evaluation, techniques, management, post-transplant care, etc.

CONCLUSION

The current text represents a consensus statement developed by a group of international experts in renal transplantation.

SECONDARY MALIGNANCIES IN DIFFERENT FORMS OF URINARY DIVERSION USING ISOLATED GUT

PURPOSE

Tumor development following ureterosigmoidostomy is a worldwide accepted late complication. In contrast, tumor risk in other forms of urinary diversion with the separation of urine and feces is still unclear. We present a complete and detailed analysis of all reported tumors following urinary diversions using isolated gut segments in the literature. We estimated the tumor risk in comparison to ureterosigmoidostomies and to the general population.

MATERIALS AND METHODS

We reviewed the world literature up to April 2003 via MEDLINE for secondary tumors in urinary diversions using isolated intestinal segments.

RESULTS

We found 81 tumor case reports following urinary diversion using isolated intestinal segments. Tumors developed in 18 conduits, 45 cystoplasties, 5 rectal bladders, 3 neobladders, 6 colonic pouches and 4 ileal ureter replacements.

CONCLUSIONS

All urinary diversions using bowel with or without separation of urine and feces carry a significantly higher tumor risk for intestinal tumor development compared to the general population. The tumor spectrum and tumor location in isolated gut segments are different than tumors following ureterosigmoidostomies but the total tumor risk is probably similar. The latency period depends on the initial diagnosis with malignant diseases leading to a shorter induction time. Concerning etiology, many theories exist but the exact mechanism remains unclear. Regular endoscopic control beginning with postoperative year 3 for early detection of secondary malignancies is mandatory.

[Gemcitabine/cisplatin vs. MVAC. 5 year survival outcome of the phase III study of chemotherapy of advanced urothelial carcinoma in Germany]

Of 405 patients with stage IV transitional cell carcinoma from an international multicenter phase III trial, 70 were randomized in Germany to receive either gemcitabine/cisplatin or standard MVAC systemic chemotherapy for locally advanced or metastatic urothelial cancer. Overall survival as the primary endpoint of the study was similar in both arms (median survival GC 15.4 months vs MVAC 16.1 months), as were tumor-specific survival and time to progressive disease. In the intent-to-treat analysis, the 5-year overall survival rate was 10% for patients randomized to GC and 18% randomized to MVAC. Tumor overall response rates (GC 54%, MVAC 53%) were similar. The toxic death rate was 0% in the GC arm and 3% (one patient) in the MVAC arm. Significantly more GC than MVAC patients experienced grade 3/4 anemia (GC 52%, MVAC 20%) with significantly more red blood cell transfusions in the GC arm.Significantly more GC than MVAC patients had grade 3/4 thrombocytopenia (GC 54%, MVAC 17%) without grade 3/4 hemorrhage or hematuria in either arm. More MVAC patients experienced grade 3/4 neutropenia (GC 56%, MVAC 61%, p=1.000), neutropenic or leukopenic fever (GC 0%, MVAC 10%, p=0.237), mucositis (GC 0%, MVAC 7%, p=0.495), and alopecia (GC 6%, MVAC 36%, p=0.004). GC represents a reasonable alternative for the palliative treatment of patients with locally advanced and metastatic transitional cell carcinoma. Sustained long-term survival was only found for patients with locally advanced cancer, lymphatic metastases, or solitary distant metastasis but not for visceral metastatic disease.

[Antibiotic induced diarrhea and pseudomembranous colitis]

The spore-forming anaerobic bacterium Clostridium difficile has become a serious enteropathogen. Oral and parenteral administration of antibiotics can cause ecological disturbances in the normal intestinal microflora. Suppression of the normal microflora may lead to reduced colonization resistance with subsequent overgrowth by pre-existing, naturally resistant microorganisms, such as C. difficile. C. difficile infection shows a range of clinical presentations between an asymptomatic carrier state, light diarrhea without inflammatory changes, and pseudomembranous colitis. C. difficile infection is acquired by the fecal-oral or environmental-oral routes. From March 2000 through March 2001 we assessed 48 cases of nosocomial antibiotic-associated diarrhea (AAD). Of these, 21 were due to C. difficile (CDAD). Cephalosporin was the agent most commonly associated with CDAD. Avoidance of cephalosporins, strict use of "single shot" prophylaxis, isolation of infected, symptomatic patients in single-bed rooms, improved hygiene and complete room disinfection lead to a rapid decrease of CDAD. The etiology, prognosis and prophylaxis are discussed in this paper.