Perioperative Outcomes of Transurethral Resection, Open Prostatectomy, and Laser Therapy in the Surgical Treatment of Benign Prostatic Obstruction: A "Real-World" Data Analysis from the URO-Cert Prostate Centers

INTRODUCTION

The aim of the study is to compare length of hospital stay, transfusion rates, and re-intervention rates during hospitalization for transurethral resection of the prostate (TUR-P), open prostatectomy (OP), and laser therapy (LT) for surgical treatment of benign prostatic obstruction (BPO).

METHODS

URO-Cert is an organization, in which clinical data of prostatic diseases from 2 university, 19 public, and 3 private hospitals and 270 office-based urologists are collected in order to document treatment quality. Data on diagnostics, therapy, and course of disease are recorded web based. The analysis includes datasets from 2005 to 2017.

RESULTS

Of 10,420 patients, 8,389 were treated with TUR-P, 1,334 with OP, and 697 with LT. Median length of hospital stay was 6 days (IQR: 4-7) for TUR-P, 9 days (IQR: 7-11) for OP, and 5 days (IQR: 4-6) for LT (p < 0.001). Risk for a hospital stay ≥7 days was higher for OP versus TUR-P (OR: 7.25; 95% CI = 6.27-8.36; p < 0.001) and LT (OR: 17.89; 95% CI = 14.12-22.65; p < 0.001) and higher for TUR-P versus LT (OR: 2.47; 95% CI = 2.03-3.01; p < 0.001). OP had a significantly higher risk for transfusions than TUR-P (OR: 2.44; 95% CI = 1.74-3.41; p < 0.001) and LT (OR: 3.32; 95% CI = 1.56-7.01; p < 0.001). Transfusion rates were not significantly different between TUR-P and LT (OR: 1.36; 95% CI = 0.66-2.79; p = 0.51). Risk of re-intervention was not different between all 3 approaches.

CONCLUSION

OP was associated with higher transfusion rates and longer hospital stay than TUR-P and LT. Risk of transfusion was not different between TUR-P and LT, but TUR-P was inferior to LT concerning length of hospital stay. Re-intervention rates during hospitalization did not differ between the groups.

[Treatment mapping of lower urinary tract symptoms due to benign prostatic hyperplasia-an analysis of the Governing Body of German Prostate Centers]

BACKGROUND

Due to the high incidence and demographic development, there is an urgent need for healthcare research data on lower urinary tract symptoms due to benign prostatic hyperplasia (LTUS/BPH). Since 2005 the Governing Body of German Prostate Centers (DVPZ) has been collecting data from 22 prostate centers in order to determine the quality and type of cross-sectoral care in particular for LUTS/BPH patients.

OBJECTIVES

Presentation of the DVPZ database in general, as well as an investigation of treatment patterns for medical and instrumental therapies.

MATERIALS AND METHODS

The analysis is based on UroCloud data sets from 30 November 2017. In the UroCloud data on diagnostics, therapy and course of disease are recorded in a web-based manner.

RESULTS

A total of 29,555 therapies were documented for 18,299 patients (1.6/patient), divided into 48.5% instrumental, 29.2% medical treatment, and 18.0% "wait and see" (in 4.3% no assignment was possible). Patients treated with an instrumental therapy were oldest (median: 72 years, interquartile range: 66-77), had the largest prostate volumes (50 ml, 35-75 ml), and were mostly bothered by symptoms (International Prostate Symptom Score = 19/4). The majority of patients under medical treatment received alphablockers (56%); phytotherapeutics were used least frequently (3%). Instrumental therapies are dominated by transurethral resection (TUR) of the prostate (60.0%), open prostatectomy (9.4%) and laser therapy (5.0%), with laser therapy having the shortest hospital stay (5 days) and the lowest transfusion and re-intervention rates (1.0% and 4.6%, respectively).

CONCLUSIONS

The DVPZ certificate covers the complete spectrum of cross-sectoral care for LUTS/BPH patients and documents the use of the various therapies as well as their application and effectiveness in the daily routine setting.

[Objective grading of prostate carcinoma based on fractal dimensions: Gleason 3 + 4= 7a ≠ Gleason 4 + 3 =7b]

BACKGROUND

Significant intra- and interobserver variability ranging between 40 and 80% is observed in tumor grading of prostate carcinoma. By combining geometric and statistical methods, an objective system of grading can be designed.

MATERIAL AND METHODS

The distributions of cell nuclei in two-dimensional patterns of prostate cancer classified subjectively as Gleason score 3+3, 3+4, 4+3, 4+4, 4+5, 5+4, and 5+5 were analyzed with algorithms measuring the global fractal dimensions of the Rényi family and with the algorithm for the local connected fractal dimension (LCFD).

RESULTS

The dimensions for global fractal capacity, information, and correlation (standard deviation) were 1.470 (045), 1.528 (046), and 1.582 (099) for homogenous Gleason grade 3 (n = 16), 1.642 (034), 1.678 (041), and 1.673 (084) for homogenous Gleason grade 4 (n=18), and 1.797 (042), 1.791 (026), and 1.854 (031) for homogenous Gleason grade 5 (n=12), respectively. The LCFD algorithm can be used to distinguish both qualitatively and quantitatively between mixed and heterogeneous patterns, such as Gleason score 3+4=7a (intermediate risk cancer) and Gleason score 4+3=7b (high-risk cancer). Sensitivity of the method is 89.3%, and specificity 84.3%.

CONCLUSION

The method of fractal geometry enables both an objective and quantitative grading of prostate cancer.

Clinical Outcome of Patients with Lymph Node-Positive Prostate Cancer following Radical Prostatectomy and Extended Sentinel Lymph Node Dissection

Objective: This study sought to evaluate the clinical outcome after extended sentinel lymph node dissection (eSLND) and radical retropubic prostatectomy (RRP) in patients with clinically localized prostate cancer (PCa). Subjects and Methods: From August 2002 until February 2011, a total of 819 patients with clinically localized PCa, confirmed by biopsy, were treated with RRP plus eSLND. Biochemical recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were assessed with Kaplan-Meier curves. Various histopathological parameters were analyzed by univariate and multivariate analysis. Results: The mean follow-up was 5.3 years. Lymph node (LN) metastases occurred in 140 patients. We removed an average of 10.9 LNs via eSLND from patients with pN1 PCa. Postoperatively, 121 pN1 patients temporarily received adjuvant androgen deprivation therapy. The mean survival periods for RFS, RFS after secondary treatment, CSS, and OS were 4.7, 7.0, 8.8, and 8.1 years, respectively. The cancer-specific death rate of the 140 pN1 patients was 13.6%. RFS, CSS, and OS were significantly correlated with pathological margin status, LN density, the total diameter of evident metastases, and membership in the subgroup ‘micrometastases only'. Conclusion: Despite the presence of LN metastases, patients with a low nodal tumor burden demonstrate a remarkable clinical outcome after undergoing eSLND and RRP, thus suggesting a potential curative therapeutic approach.

Radiochemotherapy in locally invasive non-metastatic carcinoma of the bladder

We therefore believe that our therapeutic concept is a true alternative to primary cystectomy, with comparable survival rates. We observed a high rate of functional organ preservation in long-term survivors (79% with complete remission (CR) after 5 years). Radiation bladders were rare at doses not exceeding 60 Gy. Age and co-morbidity were not exclusion criteria. Presence of a competent and cooperative radiotherapy department is a precondition to preventing akinetic radiation bladders. Continuous life-long follow-up is necessary. Cystectomy, together with modern urinary diversions, is still necessary; it is performed in non-responders and in patients with muscle-invasive recurrences.

[The frequency-doubled double-pulse Neodym:YAG laser lithotripter (FREDDY) in lithotripsy of urinary stones. First clinical experience]

Laser lithotripsy does not play an important role in urinary stone treatment, mostly due to ineffective fragmentation efficiency, and high purchase and maintenance costs. The aim of the following retrospective study was to show the clinical significance and efficiency of an innovative laser lithotripsy system for urinary stone treatment. Between November 1998 and October 1999, 48 patients were treated with the innovative frequency- doubled double-pulse Neodym: YAG laser lithotripter FREDDY. A total of 50 renal units were treated, 43 ureteroscopically, four ureterorenoscopically, three percutaneous-nephroscopically, and one bladder stone cystoscopically. With a median laser operation time of 5 min (range: 1-30 min) and a total procedure duration of 60 min (range: 15-180 min), a stone-free rate of upper ureteral stones of 62%, middle ureteral stones of 91% and distal ureteral stones of 100% were documented on the first day after treatment. In an observation period of 6 months, no complications were seen. In our experience Laser lithotripsy with FREDDY is an effective, simple and reliable method for the treatment of ureteral stones, with low purchase and maintenance costs. The extremely thin and highly flexible quartz fibre may extend the endoscopic spectrum to otherwise poorly accessible upper ureteral stones, the renal pelvis and renal calix stones. Therefore, a prospective validation study for comparison with ballistic lithotriptors is of great interest.

In vitro study concerning the efficiency of the frequency-doubled double-pulse Neodymium:YAG laser (FREDDY) for lithotripsy of calculi in the urinary tract

BACKGROUND AND OBJECTIVES

In a preclinical study we have tested both in vitro and in vivo, a new type of pulsed solid-state laser system that has not been applied in urology so far and has been developed for optimized intracorporal lithotripsy of biliary, salivary, and urinary calculi.

STUDY DESIGN/MATERIALS AND METHODS

Sixty one calculi from the human urinary tract were split in vitro into fragments with a remaining particle size of </= 2 mm using the prototype of a short-pulsed passively Q-switched and frequency-doubled double-pulse Neodymium:YAG laser. In a supplementary animal test, the bladder mucosa of five rabbits was directly exposed to a highly rated laser beam to be able to assess the tissue lesion potential of the system.

RESULTS

All the 61 urinary calculi with different composition were successfully split in vitro within a short period of time (2.5 +/- 4.6 minutes). During histopathologic examination of the exposed bladder walls of the rabbits only a small tissue lesion potential with urothelium changes exclusively at the surface was ascertained.

CONCLUSION

The high degree of fragmentation efficiency, the purchase and maintenance costs, which due to its design are substantially lower in comparison to other laser lithotriptors, and the high degree of safety during application make this new laser a real alternative not only to the present laser lithotripsy systems but also to common ballistic lithotriptors.

Preclinical studies combining bispecific antibodies with cytokine-stimulated effector cells for immunotherapy of renal cell carcinoma

BACKGROUND

Bispecific antibodies--consisting of a F(ab')-fragment derived from a monoclonal antibody against a tumor epitope as well as of another antibody against a cytotoxic trigger molecule on immune effector cells--can improve the effectiveness of antibody-based tumor therapy.

MATERIALS AND METHODS

We used bispecific antibodies with one specifity against the EGF-receptor, which is overexpressed on the majority of renal cell carcinomas, and another specifity against Fc receptors on human leukocytes (Fc gamma RI/CD64; Fc gamma RIII/CD16 and Fc alpha RI/CD89). As source of effector cells, whole blood from patients treated with G-CSF, GM-CSF or IL2/IFN-alpha was used in 51Cr- release assays using various renal cancer cell lines as tumor targets. Further experiments with Percoll-isolated granulocytes or mononuclear cells from the same donors were performed in order to identify the active effector cell populations.

RESULTS

Compared with conventional monoclonal EGF-R directed antibodies (murine IgG2a, humanized IgG1), bispecific antibodies induced significantly enhanced cytotoxicity. Highest amounts of tumor cell killing were observed using whole blood from patients treated with G-CSF or GM-CSF in combination with an [Fc alpha RI x EGF-R] bispecific antibody. Under these conditions, granulocytes constituted the most active effector cell population.

CONCLUSION

The combination of myeloid growth factors and bispecific antibodies offer a promising new approach for the treatment of advanced renal cell carcinoma.

Flow cytometric analysis of DNA-aneuploidy subgroups and proliferation in renal cell carcinoma

BACKGROUND

The course of patients suffering from renal cell carcinoma varies considerably and cannot be predicted by tumor stage and grade alone. However, it is crucial to select patients with high risk of progression and to commence adjuvant immuno-chemotherapy in good time.

MATERIALS AND METHODS

Multiple samples of 71 kidney tumors were studied by DNA flow cytometry. Aneuploidy was classified into subgroups employing the DNA-index. In tumors of euploid pattern and corresponding normal tissue cell cycle analysis was performed.

RESULTS

39% of tumors were found to be aneuploid. Mean proliferation fraction was distinctly higher in euploid tumors (15.6%) than in normal tissue (6.1%). DNA ploidy pattern correlated significantly (p < 0.05) with histological grading. With increasing tumor size the clonal spectrum changed as well: Tetraploid cell lines fell from 40% to 28%. The number of triploid clones rose from 33% to 56%.

CONCLUSION

Based on selection of tri- and hypertetraploid carcinomas, a high-risk-group for tumor recurrence can be associated within the predominating T2/3 G2 kidney tumors. The aim is to treat these patients following curative surgery at the stage of probable micro-metastases while keeping risk of overtreatment as low as possible.

Lymph node involvement in renal cell carcinoma and survival chance by systematic lymphadenectomy

BACKGROUND

The value of systematic lymphadenectomy has been a matter of great controversy for a long period of time. A recently published paper of a retrospective autopsy study generally doubts its therapeutic effectiveness, arguing that positive lymph nodes are nearly always associated with distant metastases.

PATIENTS AND METHODS

Between 1974 and 1993 1035 patients suffering from renal cell carcinoma with stages from cT 1 to 4, cM 0 were treated with curative intention. 51% underwent radical abdominal tumour nephrectomy with systematic lymphadenectomy (n = 531, group A). In 199 patients (19%, group B) only macroscopically suspect lymph nodes were removed surgically. All other patients underwent radical lumbar tumour nephrectomy without lymphadenectomy (n = 305, 29%, group C).

RESULTS

Mean age of group A was 55.5 +/- 10 years, B 60.3 +/- 11 and C 66.5 +/- 11. Median follow-up for all groups was 115 +/- 63 months. Median amount of removed lymph nodes was 18 in group A, 6 in group B and 3 in group C. N-categories for each group were pN 1: 4%, 2%, 1%; pN 2: 7%, 5%, 1%; pN 3: 3%, 2, %, 1%; pN x: 0%, 35%, 67% respectively. Group A with systematic lymphadenectomy had the least favourable tumour stage overall. Nevertheless long-term survival of this group is more favourable with 57% +/- 6 when compared to group B with 50 +/- 12% and C with 44% +/- 9%. 20 (27%) of the 75 lymph node positive patients of group A who have been followed-up for more than 5 years are still alive.

CONCLUSIONS

At least 4% of all patients benefit from extensive lymphadenectomy. This may only be a relatively small proven effect for the entire patient collective, but for a single lymph node positive patient this is an undoubtedly significant additional chance of survival especially when one notes that presently there is no curative adjuvant therapy.

[Interdisciplinary surgical therapy of renal tumors with intracardiac tumor thrombi]

A combination of increased perioperative morbidity, together with the technical difficulty of an R 0 (curative) resection, is responsible for the poor prognostic factors of supradiaphragmatically extending renal tumors. Six patients aged 53-70 years with vena cava thrombosis extending into the right atrium or ventricle underwent en bloc resection of the primary tumor and tumor thrombus removal. If the atrial tumor mass was large or extended into the ventricle, resection was performed during cardiopulmonary arrest using a cardiopulmonary bypass method with the patient in deep hypothermia (< 18 degrees C). Alternatively if the cardiac tumor infiltration was minimal, resection was performed during an optionally short cardiopulmonary arrest period using a cardiopulmonary bypass method with the patient in hypothermia (23 degrees C). The operative procedure was determined by intracardiac tumor extension, tumor wall adhesions and tumor wall infiltrations, all of which were assessed intraoperatively by vena cava sonography. Six patients were strongly symptomatic preoperatively. Three developed sudden life-threatening cardiopulmonary insufficiency, possibly due to longer-lasting tricuspital valve prolapse with a consecutive right-to-left shunt through a newly reopened foramen ovale. One patient died 14 months postoperatively because of multiple metastases (hepatic, pulmonary and bone). One patient is still alive and has had a local recurrence for 2 months, which was diagnosed 65 months postoperatively. The remaining four patients are alive and well. They have been tumor-free for extended periods of time (29, 34, 62 and 84 months, respectively).

[Ureteral injuries caused by external force]

The pathologic mechanism responsible for ureteral injuries is no different now than in past decades. Nowadays, however, we distinguish diagnostically between partial traumatic tears and complete ones. This distinction leads to different therapeutic strategies: endoscopic surgery for the former and open surgery for the latter. We further distinguish between the pathophysiology of closed and of open urinomas; the latter have a less favourable prognosis. This means that the treatment strategies and the degree of urgency are also different. We report on 16 cases treated over the past 22 years and review the international literature.

[Kidney transplantation in patients with anomalies of the lower urinary tract]

In the transplant centre in Erlangen-Nuremberg, 1242 patients underwent renal transplantation between 1966 and 1993. In 4.5% of cases (56 patients) the renal end stage disease had been caused by severe abnormalities or functional disturbance of the lower urinary tract. Despite long-standing defunctionalization, urinary diversions and multiple operative procedures, it was possible to use the original bladder for ureterocystoneostomy in all patients. Only 1 patient needed an enterocystoplasty after transplantation. Altogether 72 transplantations have been performed in 56 patients ranging from 10.2 to 62.7 years of age. At follow up, 40 patients (71%) had a functioning graft with a mean serum creatinine level of 1.5 mg%. The 5-year transplant survival rate is 57.3%. Our results suggest that carefully planned renal transplantation in urological patients has results comparable to those obtained in other, non-risk, kidney transplant recipients. The methods of bladder reconstruction and augmentation, intermittent self-catheterization as well as anticholinergics and continuous antibiotic prophylaxis combine to make the ileal or colonic conduits needed earlier unnecessary.

[Classification and prognosis of supravesical urothelioma with the new TNM classification]

We report on 149 patients with supravesical urothelioma (transitional cell carcinoma of the upper urinary tract) treated in our hospital during the years 1967-1991. The introduction shows the distribution of sex and age as well as the localization of the tumor. Main topic of this paper is a new definition of the clinical pathology of supravesical urothelioma by means of the TNM classification published 1987. Based on the pathological pioneer work of P. Hermanek our results are as follows: during the first diagnosis pT3 predominates with 30.2%, followed by pT1 with 25.5% and pTa, pT1 and pT4 with a relatively low incidence. G2 predominates with 47.7%; G1 and G3 have almost the same frequency. The G/pT ratio shows a decreasing linearity for G1 from pTa to pT4; for G2 there is equivalence of pT1-pT3; and pTa and pT4 are relatively rare. With respect to G3, pT3 predominates with 51%, followed by pT4, pT1 and finally pTa with zero frequency. The G/M ratio shows M0 only for G1, 10% M positive for G2 and 15% M positive for G3. The 10-year survival rate for patients with R0 resection and stage pTa is 64% and for pT1-pT4, 33-36%. The 10-year survival rate for patients with G1 tumor is 51%, and that for G3 tumors 30%. Multicentric occurrence and carcinoma in situ have no prognostic significance in our sample. As is well known, papillary growth has a better prognosis than solid infiltration.(ABSTRACT TRUNCATED AT 250 WORDS)

[The significance of tumor diameter in renal cell carcinoma]

The data of 740 patients who were operated on for renal cell carcinoma between 1975 and 1986 have been evaluated. We studied the relation between tumour size and other factors influencing the prognosis, such as tumour stage, infiltration of renal veins and incidence of metastases at the time of nephrectomy, and between tumour grading and postoperative survival. Sixty-six patients with small tumours were divided in groups according to tumour size: less than 20 mm, less than 25 mm, less than 30 mm, less than 40 mm. All 740 patients were separated into groups according to tumour size: less than 4 cm, 4-6 cm, 6-8 cm, 8-10 cm and greater than 10 cm. Stage pT1 carcinomas (less than 25 mm) occurred in 1.4% of patients and tumours exceeding 10 cm in size in 30%. The prognosis with regard to survival becomes worse the greater the diameter of the tumour: the incidence of renal vein involvement, metastases and higher grades of malignancy increases. Postoperative survival decreases in relation to the increase in tumour size. Carcinomas less than 30 mm in diameter were found to have distant metastases in only 1 case, while invasion of renal veins occurred in 2 cases. In tumours up to 3 cm in diameter, a kidney-preserving tumour resection seems possible without limiting the radicalness of the surgery.

[Laser lithotripsy of ureteral stones. Personal experiences]

The in vitro evaluation of a pulsed Nd:YAG laser, showed an effective and fine fragmentation of urinary calculi and showed only minimal subepithelial bleeding in the directly irradiated canine ureter. Since 1989 we have treated ureteral calculi in 30 patients. The laser pulses of 15-20 mJ (at fiber tip), 20 ns, 20-25 cps are transmitted by a 300-microns quartz fiber with a specially formed tip focusing the light. The fiber is passed through an 11.5-F ureteroscope within a guide tube, or, without a guide tube, through one of the new minimized ureteroscopies and is placed in front of the calculus. In 27 patients the procedure was successful, without any residual concretions after 1 day. In our opinion the advantages of this method are the very fine-grained, complete fragmentation of all sorts of calculi, the highly atraumatic procedure, and the absence of either optical or acoustic irritation to the operator.

[Adrenal apoplexy--endogenous, exogenous and therapeutic multiplicity]

From the aspect of morbidity, adrenal apoplexy is primarily a disease of newborns or infants, frequently with subclinical rather than frank manifestations. The development is governed by the susceptibility fetal processes of adrenal transformation to disturbances and injury. Exogenous causes such as birth trauma and bacterial inflammation, are seen in some cases, as are sympathogenous neoplasms. When it is diagnosed some uncertainty about benign or malignant development of the disorder persists in the background. With sonography now available as a diagnostic tool, in the majority of the cases conservative monitoring for a tendency to spontaneous resorption is enough. This approach, however, also involves the risk of identifying a protracted circulatory shock or the growth of an adrenal tumor too late. The surgeon also faces the problem of possible misinterpretation of hematoma impacted into the fascia of the capsule of Gerota as a nephroblastoma with consequent erroneous treatment. The relative rareness of the disorder means surgeons have little personal experience with it, which compounds the difficulties. In comparison with the situation in children, treatment of the adult form of the disorder appears almost simple.