False-negative finding in urodynamic study for the chief complaint. Does it interfere with the clinical outcomes for the treatment of SUI or OAB syndromes?

Purpose:

False-negative urodynamic findings may mislead or prevent planned treatments due to unmatched findings with the clinical presentation. We hypothesized that the absence of urodynamic demonstration of SUI or OAB on urodynamics would interfere with clinical outcomes.

Materials and Methods:

Materials and Methods: We prospectively studied 124 women with (94) or without (30) demonstrable SUI after sling operations. Similarly, 64 women with OAB syndrome with (38) or without (26) demonstrable DO were also compared after treatment with anticholinergic agents. Patients were assessed with the UDI-6 and IIQ-7 questionnaires 3 and 6 months after treatment.

Results:

Only 76% of SUI patients demonstrated urine leakage during urodynamics. The UDI-6 score was higher in the demonstrable-SUI and demonstrable-DO groups, while the IIQ-7 score was comparable within the incontinence or urgency/frequency groups. Demonstrable and non-demonstrable SUI-operated patients showed similar outcomes. Patients with urgency syndromes with or without demonstrable DO had a similar rate of improvement with anticholinergic therapy.

Conclusions:

Women with clinical complaints of SUI objectively demonstrated on urodynamics presented the same subjective clinical outcome as those with SUI lacking objective demonstration when measured by the UDI-6 and IIQ-7 questionnaires. Similarly, patients with OAB syndrome with or without demonstrable DO had similar clinical improvement when treated with anticholinergics and measured using the same questionnaires.

Rate of spontaneous voiding recovery after acute urinary retention due to bed rest in the hospital setting in a nonurological population clinical study of the relationship between lower limbs and bladder function

Objectives

To understand the clinical relationship between lower limbs functions and the recovery of spontaneous voiding after an acute urinary retention (AUR) in older patients admitted to hospitals for non-urological causes using clinical parameters.

Materials and Methods

56 adult patients (32 men; mean age: 77.9 ± 8.3 and 24 women; mean age 82.1 ± 4.6) with AUR were prospectively followed with validated Physical Performance Mobility Exam (PPME) instrument to evaluate the relationship between the recovery of mobility capacity and spontaneous voiding. After a short period of permanent bladder drainage patients started CIC along evaluation by PPME during hospitalization and at 7, 15, 30 60, 90, and 180 days of discharge. Mann-Whitney U, chi-square test and ANOVA tests were used.

Results

All patients were hospitalized for at least 15 days (Median 26.3 ± 4.1 days). Progressive improvement on mobility scale measured by PPME was observed after leaving ICU and along the initial 7 days of hospitalization but with a deterioration if hospitalization extends beyond 15 days (p<0.03). Prolonged hospital stay impairs mobility in all domains (p<0.05) except step-up and transfer skills (p<0.02) although a recovery rate on spontaneous voiding persistented. Restoration of spontaneous voiding was accompanied by improvement on mobility scale (p<0.02). Recovery of spontaneous voiding was markedly observed after discharging the hospital. All patients recovered spontaneous voiding until 6 months of follow-up.

Conclusions

Recovery to spontaneous voiding after acute urinary retention in the hospital setting may be anticipated by evaluation of lower limbs function measured by validated instruments.

Can We State Stable Bladder? How Many Repetitions Should We Do for an Appropriate Demonstration of Involuntary Detrusor Contraction?

AIMS

Involuntary Detrusor Contraction (IDC) may alter therapeutic plans; therefore, urodynamic demonstration (UD) is pivotal. We explore if same session repetitions enhance its demonstration and minimize false-negative results.

METHODS

Two hundred fifty two women (mean age 47 ± 5.7) had 4 full repetitions of UD with the last round filled with 4°C fluid (Ice-water test). IDC was diagnosed if with at least 3 cm H2O after artifacts were ruled out.

RESULTS

44.4% of the cases showed IDC in the first round of the exam but it could be demonstrated in 88.5% of the women if 4 rounds are taken into account. Only 2 cases showed IDC exclusively in the first round. Nine cases (3.5%) showed IDC in the first round and only on Ice-test, while all other IDC-detected cases revealed it in scattered patterns along the repetitions. Likewise, IDC detection on the second, third and fourth rounds varied widely and unpredictably, many failing to show a consistent pattern of presentation after its detection. IDC wave amplitude did not show any correlation to the detection.

CONCLUSIONS

Urodynamic repetition is a necessary procedure where IDC is important to demonstrate, as its false-negative rate is high and its unpredictable pattern of detection may be improved by repetition.

One hundred cases of SUI treatment that failed: a prospective observational study on the behavior of patients after surgical failure

OBJECTIVES

Determine what happens to patients after unsuccessful SUI operations and to explore the reasons why these patients change doctors.

MATERIALS AND METHODS

One hundred consecutive failed patients treated for SUI were interviewed about the exams requested after persistence of the incontinence as well as the reasons they abandoned their primary doctors through a structured questionnaire.

RESULTS

Among the patients with cases of anterior colporrhaphy, bladder suspensions or slings, 34.3%, 13.7% and 8.3%, respectively, were not offered any further type of investigative procedures to clarify the failure. Urodynamic evaluations were recommended in 75% of failed slings, and 66.6% of the patients proceeded with these tests. In contrast, only 31% of patients with bladder suspensions and 40% of patients with anterior colporrhaphy were recommended for urodynamic investigations, and only 44.4% and 28.5% of them, respectively, proceeded with the option. Patients' delusions were reinforced by the doctors' attitude toward the investigations. Vacuous justifications and the lack of intention to seek improvement were the driving forces causing the patients to change doctors.

CONCLUSION

Unsuccessful patients are evaluated in a non-protocol form. Difficulty in clarifying the reasons for surgical failure and the disruption of the doctor-patient relationship are the main reasons why patients abandon them.

Urodynamic after-contraction waves: a large observational study in an adult female population and correlation with bladder and ureter emptying functions in women

OBJECTIVE

To evaluate different patterns of after-contraction (A-C) waves detected during urodynamic evaluation in women.

PATIENTS AND METHODS

4,110 women were prospectively observed regarding the presence of A-C waves upon urodynamic evaluation. Intravenous pyelography and ultrasound were requested. Paired t test, χ(2) test, Wilcoxon's rank sum test and correlation analysis were performed with a 95% significance level.

RESULTS

There were three distinguishing patterns of A-C: type I - detrusor contraction after the regular voiding phase, type II - detrusor contraction persisting after the flow rate had stopped, and type III - rebound of the detrusor contraction after the flow. A-C was observed in 13.9% of the women. Type I A-C wave patterns were present in 68 patients (11.8%), type II A-C wave patterns in 477 patients (83.2%), and type III A-C wave patterns in 28 patients (10.3%). Studies with intravenous pyelography and ultrasound very frequently showed bladder mucosa, muscle thickening or trabeculation. Secondary ureterectasis related to A-C waves was also observed. Additionally, watts factor, maximum flow rate, detrusor pressure and opening detrusor pressure were markedly elevated in patients with type III A-C, suggesting enhanced detrusor contraction in these A-C waves.

CONCLUSION

A-C waves are a real urodynamic entity with different patterns of presentation and with clinical and morphological alterations.

Involuntary detrusor contraction is a frequent finding in patients with recurrent urinary tract infections

OBJECTIVE

To check whether subtle voiding dysfunction is related to recurrent urinary tract infection (rUTI).

METHODS

254 consecutive patients with at least four episodes of urinary tract infection (UTI) were studied. At least three repeat urodynamic evaluations with an additional ice water test to maximize the detection of involuntary detrusor contraction (IDC) were used. Stress urinary incontinence cases were used as controls. Nonparametric univariate and multivariate analyses were used for statistics.

RESULTS

IDC was detected in 83.6% of patients in the rUTI group and in 31.7% in the control group. IDC was <15 cm H2O in 54.7% whereas high-amplitude (>50 cm H2O) IDC was observed in 6.8% in the rUTI group. Female urinary tract obstruction was diagnosed in 16.8% of patients in the rUTI group and in 7.9% in the control group. Residual volume, PdetQmax and Qmax were not predictive of UTI recurrence. Symptoms were similar in both groups.

CONCLUSIONS

Patients with rUTI present with covert bladder dysfunctions represented by detrusor overactivity.

Impact of Urodynamic Learning on the Management of Benign Prostatic Hyperplasia Issue on Young and Senior Urologists and Reasons to Attend a Voiding Dysfunction Course

OBJECTIVES

The aims of this study were to compare the impact of urodynamic training on the young urologists after fellowship training as well as on senior urologists who attend regular courses on the management of benign prostatic hyperplasia (BPH) and their capacity to do and interpret urodynamic studies.

METHODS

Sixty-four consecutive young urologists admitted to fellowship program on voiding dysfunctions and 110 senior urologists attending to periodical meetings were interviewed before and after the 3-day-courses regarding their ability to set, interpret and do urodynamic studies. They were also questioned on the reasons that led them to attend the courses and how they use the new concepts to manage BPH. A rank of the used parameters to indicate transurethral resection of the prostate (TURP) in BPH patients were scored before and after the course.

RESULTS

Fellowship and senior urologists mainly attended the course because of lack of confidence and belief that this urological issue is too important to be disregarded. A significant portion of both groups do not trust third-party examiners. More than 90% of the urologists acquired confidence in interpreting, setting and were able to do the exam after the course. The majority of both groups believed urodynamic study was essential to manage BPH, disregarding volume as the main reason to operate on patients. Many outdated parameters became less important on the decision to operate.

CONCLUSIONS

Doctors exposed to intensive or long urodynamic training dramatically changed their perceptions on the utility of this tool and became more attentive it.

Female obstruction after incontinence surgery may present different urodynamic patterns

INTRODUCTION AND HYPOTHESIS

The aim of this study is to report a novel understanding of the urodynamic parameters used to diagnose iatrogenic female obstruction. There is no consensual definition of infravesical obstruction in women. Numerous criteria were designed with arbitrary cutoff values with poor clinical correlation. In order to determine the urodynamic profile of infravesical female obstruction we restricted our analysis to women who acquired voiding disturbances after being submitted to stress urinary incontinence (SUI) surgery.

METHODS

A total of 302 women developed obstructive symptoms or voiding difficulties after SUI operations: 176 cases had had Kelly-Kennedy operations (58.2 %), 50 had had Burch operations (16.5 %), 37 (12.2 %) had had anterior colporrhaphy + abdominal (Burch) operations, 33 (10.9 %) had had sling operations, and 8 (2.6 %) had had Marshall-Marchetti operations. Obstructive urinary symptoms started in 1-120 days after the operation and urodynamic evaluations were done after various periods of time (median 18.4 months). Clinical presentations varied widely with irritative symptoms predominating the picture.

RESULTS

Five patterns of pressure-flow relationships could be identified: (1) elevated pressure and poor flow (7.2 %), (2) normal pressure and poor flow (41.5 %), (3) normal pressure and flow associated with prolonged flow time (24.2 %), (4) poor detrusor contraction and elevated residual volume (12.9 %), and (5) elevated pressure and high flow (14.5 %). No relationship was established amongst the group and the Urinary Distress Inventory questionnaire.

CONCLUSIONS

Infravesical obstruction in women does not fit a single model. As suggested, obstruction in women must be based on broad clinical pictures and urinary complaints.

The role of a surgical learning curve in urethral obstruction following autologous fascial sling: a case-series study

INTRODUCTION AND HYPOTHESIS

Iatrogenic female urethral obstruction resulting from sling operations may be related to surgical inexperience and must be better understood. Although there are no widely recognized parameters for this type of study, a single-surgeon consecutive series offers an opportunity to study the role of expertise in sling operations over time.

METHODS

This study consecutively examined 176 women who underwent an autologous fascial sling procedure. Postoperative urethral obstruction was identified by the occurrence of voiding dysfunctions. Clinically obstructed patients were invited to undergo a postoperative urodynamic evaluation after 3 months. To enable comparison, patients were placed into 6-month groups according to the time of surgery.

RESULTS

A total of 159 cases were evaluated with a mean follow-up time of 32.4 ± 13.4 months. Stress continence was cured in 97.5% of cases. Although 29 patients were identified as obstructed, only 20 underwent a postoperative urodynamic evaluation. Only five of the clinically obstructed cases showed a high P(det)Q(max). All of the other cases met one or more of the non-classic parameters linked to obstruction. Overactive bladder was present in 14 (63.6%) of the obstructed cases. Iatrogenic urethral obstruction was more common among the early cases (30.4%) than among the later ones (5%) (P < 0.001). Postoperative urodynamic evaluation showed a trend toward obstruction on pressure flow studies.

CONCLUSIONS

Autologous fascial sling operations require expertise and involve a clear surgical learning curve. Iatrogenic obstruction in females does not fit a single model and may be difficult to recognize. Obstruction in females must be identified through clinical indicators and postoperative urinary complaints rather than the high detrusor pressure observed in men. Furthermore, iatrogenic female obstruction can probably be minimized but not eliminated.

[Testicular toxoplasmosis: a rare case of a testicular mass]

Toxoplasma gondii is an intracellular protozoan infecting birds and mammals. Acute infection is asymptomatic in immune competent people. For immune deficient patients (acquired immune deficiency syndrome, lymphoma patients or those under steroids to prevent organ transplantation rejection) infection may be lethal. We describe an uncommon case of testicular toxoplasmosis in patient under steroids after organ transplantation with no positive serum test for HIV and/or systemic toxoplasmosis.

Titration of dosage of the protective effect of zoledronic acid in patients submitted to androgen-deprivation therapy due to CaP

15561

Background: Androgen-deprivation therapy is gold-standard treatment for advanced CaP. Zoledronic acid has become a new adjuvant drug for osteoporosis prevention and pain control in patients submitted to androgen-deprivation therapy but regimen of administration is not consensual. Many off-label regimens are used on different occasions. Methods: 64 patients (mean age: 71.7 y-o) after being diagnosed with non-intended to cure therapy were initiated with androgen-deprivation with LHRH agonists at the same time they initiated no treatment (control-16 cases) or monthly (12), bi- monhtly (10), tri-monthly (14) or semestral (12) zoledronic acid infusions for 24 months. Lumbar BMD were evaluated periodically with dual- energy X-ray absorptiometry with densitometry in L2-L4 at 6-month intervals. Tuckey-Kramer and Scheffe`s tests were used for statistical significance of 0.05. Results: Control patients revealed a subgroup showing progressive diminishing BMD along the studied period while another sub-group remained stable. Patients receiving treatment with zoledronic acid showed increasing BMD at the lumbar area (p <0.05) for the 4 treated groups. The protective effects of lumbar BMD were remarkable starting at 18 months in the 4 treated groups with progressive increase of BMD with no clear advantage to any particular regimen (p >0.05). Bone protection could be achieved in the 4 treated groups with no differences for the monthly, bimestral, trimestral or semestral infusions. Conclusions: Zoledronic acid is effective in decreasing bone loss after androgen-deprivation therapy compared to no treatment for osteoporosis. Titration of the dosage regimen of the infusions showed no statistical advantage for any temporal regimen. Reasons for that can only be speculative at this time.

[Table: see text]

No significant financial relationships to disclose.

Natural rubber latex sensitisation and allergy in patients with spina bifida, urogenital disorders and oesophageal atresia compared with a normal paediatric population

BACKGROUND

Natural rubber latex (NRL) contains proteins which, after repeated contact with latex products and an allergic predisposition (atopy), can lead to sensitisation (specific IgE against NRL proteins) or allergy (type 1 allergy with symptoms from urticaria to allergic shock). Spina bifida patients are known to be a high risk group for latex allergy and sensitisation due to numerous operations beginning soon after birth. In the study presented here we compared spina bifida patients with patients who also underwent repeated operations beginning soon after birth (urological malformations) or underwent surgery once in the neonatal period but had numerous anaesthesias because of repeated treatment with a bougie (oesophageal atresia). In this setting the influence of surgery and anaesthesia on NRL-sensitisation was investigated.

MATERIALS AND METHODS

We investigated the prevalence of NRL-specific IgE (> 0.35 kU/l, ImmunoCAP system, Pharmacia) in a normal paediatric population (neither atopic nor having undergone surgery) (group I), spina bifida patients (group II), children with urogenital malformations (group III) and children with oesophago-tracheal malformations (group IV).

RESULTS

The highest rate of NRL-sensitised patients was found in the spina bifida group (II) (48 %), followed by groups III and IV with 17 % each, compared to 4 % for the control group. NRL-allergic reactions were noted only in the patients with spina bifida and the urological malformation group (18 % in group II, 8 % in Group III). Apart from atopy the number of operations could be identified as a risk factor for the development of NRL-sensitisation and allergy (group II, III). The prevalence of latex allergy was lower after repeated anaesthesia (group IV) than after repeated surgery.

CONCLUSIONS

In addition to the known high risk group of spina bifida patients, other patients with congenital malformations and early surgery also have a significant risk for latex sensitisation. When treating patients with malformations requiring repeated surgery, prophylactic measures similar to those for spina bifida patients should be considered.

Pubo-fascial versus vaginal sling operation for the treatment of stress urinary incontinence: a prospective study

AIMS

To compare the long-term results of stress urinary incontinence (SUI) treatment involving the fascial or vaginal sling operations.

MATERIAL AND METHODS

Two-hundred-thirty-two women were consecutively submitted to fascial or vaginal sling operations due to urodynamic proven SUI. The fascial group had a median age of 47.3 years with a parity of 2.2 and 1.8 surgeries/patient, while the vaginal group demonstrated a median age of 48.5 years with a median parity of 3.1 and 2.2 anterior surgeries/patient. The results were subjectively classified as cured--no further pads, greatly improved--very rare dribbling, improved--eventual dribbling necessitating one pad, no cure--with no urine loss change and worse. The number of pads/day, the presence of urgency or urge-incontinence episodes were all measured. Statistical analysis using Fisher's exact test was employed.

RESULTS

The patients were followed up for an average time of 70.3 and 44.9 months, in the fascial and vaginal sling group respectively. Subjective clinical success rate was 93.7% for the fascial sling group and 79.8% for the vaginal one, however, the stratification of the results favored the fascial sling group mostly with 74.4% (94 cases) of the cases with total urinary control and no voiding dysfunctions. Only two cases (1.6%) in this group classified themselves as worsened. On the other hand, the vaginal sling subset revealed cure with total clinical satisfaction and no urinary complaint in 61.5% (62 females) (P > 0.05). Thirteen cases (12.5%) reported recurrence of the urine loss under stress and these constituted the failure group. The average number of pads diminished from 3.3 (+/- 0.8) to 0.2 (+/- 0.2) and from 3.2 (+/- 0.7) to 0.6 (+/- 0.5) after the surgery, for the fascial and vaginal sling operations respectively. Return to daily activities occurred after 9.3 days (+/- 1.2, max: 33, min: 2) for the fascial slings and 5.3 days (+/- 0.2, max: 17, min: 2) in the vaginal group. Surgical complications were compared between the groups. Time to urethral voiding varied according to expertise, demonstrating a diminishing tendency after the initial 20 cases. Female obstruction was observed in 11.1% of the fascial slings and 8.6% after vaginal approach, but none in the vaginal group required urethrolysis. Looking individually, the FS group migrated to the worse results while the VWS group started to lose the efficiency after 6 months.

CONCLUSIONS

Sling operations are a safe and efficacious option to treat SUI, however, the results can vary according to the technique employed. Shorter efficacy and fewer complications are observed in vaginal wall sling operations, while durable results, but with a higher rate of voiding dysfunctions compromising the long-term clinical satisfaction may be observed after excessive urethral suspensions, as in fascial sling suspension.

Use of bisphosphonates can dramatically improve pain in advanced hormone-refractory prostate cancer patients

INTRODUCTION

Approximately 85% of patients who die from prostate cancer present the spread of bone metastases. Even though the radiological appearance of such metastases is osteoblastic, it is now known that these lesions coexist in their microenvironment with blastic and lytic lesions. The process always begins with bone lysis by osteoclast proliferation, paralleling nearby bone deposition. The treatment options are palliative and have poor clinical response with short-lived improvement. We have studied the clinical effect of bisphosphonates (clodronate) in the treatment of skeletal complications from prostate cancer.

MATERIALS AND METHODS

In an open prospective study, 58 patients with hormone-refractory prostate cancer with bone metastases were assessed from November 2000 to September 2003. The mean age was 70.3 y (range: 51-87 y). Bone scintigraphy, plain X-ray, assaying of prostate-specific antigen (PSA) and biochemical tests were requested before and following treatment. Patients were previously and subsequently assessed using the visual pain scale (0-10) and Karnofsky's index after the first and second intravenous (i.v.) infusions (administration of i.v. clodronate every 28 days) and every 4-6 months thereafter. Student's t-test was used for statistical analysis.

RESULTS

A total of 53 patients (91.4%) showed improvement after the first and/or second cycle, which persisted for at least 4 months (average 6.3 months). The averages on the visual pain scale improved from 7.4 (range: 2-8) to 2.4 (0-7) and on Karnofsky's index from 43 (32-58) to 73 (50-82). The radiological appearance of the metastases improved in 27 patients (46.5%) and there were few relapses (six patients; 10.3%).

CONCLUSIONS

Clodronate was effective in the treatment of skeletal complications from prostate cancer. There was an objective response in 91.4% of treated patients, with a marked improvement in the subjective visual pain scale evaluation as well as on Karnofsky's index, with low side effects.

Low clinical stage renal cell carcinoma: relevance of microvascular tumor invasion as a prognostic parameter

PURPOSE

Renal cell carcinoma is a tumor with unpredictable behavior and defining reliable prognostic factors would be extremely valuable in the clinical setting. Tumor stage, nuclear grade and tumor cell type are the main prognostic clinical parameters available. In this study we evaluated the role of microvascular involvement in the primary lesion for predicting tumor behavior in patients with low stage clinical disease.

MATERIALS AND METHODS

A total of 95 patients with clinically localized renal cell carcinoma (stages T1-T2 Nx M0) underwent radical nephrectomy and/or nephron sparing surgery, and were followed for a median of 45 months. The impact of microvascular tumor invasion on disease progression and its correlation with known pathological outcomes (tumor size, nuclear grade and cell type) were studied.

RESULTS

Microvascular tumor invasion was observed in 24 patients (25%), of whom 50% had disease recurrence. Of the 71 patients without microvascular invasion only 4 (6%) showed tumor recurrence. When microvascular invasion was correlated with other histological parameters, a significant statistical association was noted with tumor diameter, perirenal fat invasion, macroscopic extension to the renal vein, nuclear grade, lymph node metastasis and sarcomatous elements in the tumor. Multivariate analysis showed that microvascular invasion and the involvement of regional lymph nodes were independent predictors of disease recurrence. Concerning cancer specific survival, microvascular invasion and perirenal fat infiltration were the only factors related to death.

CONCLUSIONS

Microvascular invasion is an independent and relevant clinical prognostic parameter for low clinical stage renal cell carcinoma.

Capecitabine in hormone-resistant metastatic prostatic carcinoma - a phase II trial

The objective of the trial is to evaluate the efficacy of capecitabine in patients with metastatic hormone-resistant prostate carcinoma (HRPC), in terms of prostate-specific antigen (PSA) response and clinical benefit (decrease of pain or analgesic score) and its safety profile. In all, 25 patients with HRPC were enrolled on a phase II trial of capecitabine (Xeloda) at a dose of 1250 mg m(-2) orally twice daily on days 1-14 every 21 days. The inclusion criteria were PSA serum levels >3 x upper limit of normal, a WHO performance status 0-2, age <85 years and adequate bone marrow, liver and renal function. In patients with grade 2 or higher haematological toxicity on day 1 of the treatment cycle, therapy was first delayed, and then continued at a lower dose. Trial end points were PSA response and clinical benefit defined by quality of life (QL) data and analgesic consumption. The median age of patients was 70 years (range 54-85 years). A median of three cycles of capecitabine was administered (range 1-8). PSA response was observed in three patients (12%, 95% CI 3-31%), with times to tumour progression of 18, 21 and 35 weeks, respectively. In these patients, the response durations were 12, 17 and 32 weeks, respectively. Minor PSA regression was also seen in two further patients. The median time to tumour progression of all patients was 12 weeks (95% CI 9-15 weeks). Haematological toxicity was minor, with leukopenia grade 3 observed in one patient. There were three deaths during trial treatment, respectively, due to sepsis following mucositis and leukopenia, presumed sepsis with mucositis induced by chemotherapy and concomitant radiotherapy and cerebral dysfunction progressing to coma. Hand-foot syndrome grades 2 and 3 were observed in four patients each. Clinical benefit was observed in five patients (20%, CI 7-41%). Based on toxicity data, we recommend a lower starting dose of 1000 mg x m(-2) orally twice daily. While capecitabine has some activity in HRPC, as suggested by observed PSA responses, we conclude that it is not worthwhile to investigate capecitabine monotherapy in a phase III trial. Combinations of capecitabine with other agents, such as vinorelbine or docetaxel, may prove to be more effective.

A randomized and prospective study on the value of antibiotic prophylaxis administration in transurethral resection of the prostate

CONTEXT

Antibiotic prophylaxis in transurethral resection of the prostate is a regular practice in urology. However, its prophylactic effect can be questioned when the antiseptic surgical technique is used. Nonetheless, urine culture-oriented antibiotic therapy is the gold standard for avoiding improper medication usage and bacterial resistance.

OBJECTIVE

To study the efficacy of antibiotic usage in patients with negative urine cultures, who were submitted to transurethral resection of the prostate.

TYPE OF STUDY

Prospective open labeled study.

SETTING

Tertiary care referral hospital.

PARTICIPANTS

124 consecutive patients, who were randomly divided into two groups to receive antibiotic prophylaxis or not.

MAIN MEASUREMENTS

Cultures from meatus, urine, irrigation and antiseptic fluid, and prostate tissue chips, were compared and analyzed for bacterial sensitivity to the antibiotic used, according to the surgeon's personal criteria. McLennan's test was used for statistical analysis.

RESULTS

No statistically significant difference regarding clinical evolution was found between the groups that received or antibiotics or not. Statistical significance was found regarding the occurrence of positive urine cultures during the postoperative period for those not receiving antibiotics, but not in relation to fever, prostate chip culture or bacteremic episodes. Sixty-eight subjects (57.1%) presented positive prostatic tissue culture. There was no specific correlation between the recovered bacteria from the meatus, prostatic tissue chip and urine and the spectrum of the administered antibiotic. Six cases showed the same bacteria in the urine and prostatic tissue chip. Only fifteen cases (25%) in the antibiotic group showed the desired sensitivity directed to the collected bacteria.

CONCLUSIONS

Antibiotic prophylaxis for patients whose urine is sterile is debatable in patients who are candidates for transurethral resection of the prostate. Most of the time, the antibiotic agent used is not specific for any of the bacteria recovered from the various sources analyzed.

Carcinoma de células renais incidentais e sintomáticos: fatores patológicos e sobrevida

BACKGROUND

Patients with early diagnosis of renal cell carcinoma (CCR) have higher chance of cure following surgical treatment. This study was set to compare the pathological characteristics between the surgical specimens and the survival of the patients with incidental and symptomatic CCR.

METHODS

One hundred and fifteen patients with sporadic CCR were studied retrospectively following nephrectomy and divided into two groups. Group 1; 59 patients with incidental diagnosis and Group 2; 56 symptomatic patients. The mean age of the patients was 59 years, with 86 men and 29 women. Radical nephrectomy was performed in 96 patients and the conservative surgery was performed in the remaining 19. Comparison parameters included pathological outcome, specifically nuclear grade, pathological stage, size of the tumor and presence of microvascular invasion intratumoral and patients survival.

RESULTS

Comparison between the two groups confirmed that the incidental tumors have smaller nuclear grade (p=0.003), smaller size (p=0.001), smaller incidence of microvascular invasion (p<0.001) and lower stage (p<0.001). Disease specific survival and recurrence free survival of the incidental group were statistically higher than the symptomatic group (p<0.001).

CONCLUSION

Incidentally discovered CCR have more favorable pathological characteristics, the patients have disease free survival when compared to symptomatic CCR.

[Must the TNM staging of the renal cell carcinoma be modified again?]

OBJECTIVE

The behavior of the renal cells carcinoma stage PT1 is not completely clarified. We studied the presence of factors after prognostics and tumoral size in the recurrence of survival of the sporadic kidney carcinoma after surgical treatment.

METHODS

120 patients followed after nephrectomy had been revised retrospectively 93 PT1, 9 PT2, 11 PT3, 7 PT4, It was analyzed survival and recurrence of the disease inside of three groups of tumors: Group 1: < 4cm, group 2: 4-7cm and group 3: > 7cm, and the prognostics factors above-mentioned evaluated were nuclear degree, microvascular invasion, presence of committed ganglia and sarcomatous degeneration.

RESULTS

The frequency of adverse prognostics factors increase as the tumor size increase. In the group 1, we had only four tumors of high degree and only one shown microvascular invasion that does not committed ganglia or sarcomatous degeneration. In group 2 there was 16 tumors of high degree, 4 sarcomatoses, two with positive microvascular invasion and two with positive ganglia. In group 3, was found 18 tumors of high degree, 15 with microvascular invasion and 7 with positive ganglia and 5 sarcomatoses. There was statistical significance in the specific cancer survival (p=0.002) and free of illness (p=0.0002) between the three groups.

CONCLUSION

The evolution of tumors PT1 is distinct for lesser tumors of 4 cm and 4-7 cm fitting the subdivision of these two groups in T1a and T1b.

Reduction of latex sensitisation in spina bifida patients by a primary prophylaxis programme (five years experience)

Spina bifida patients represent a group with the highest risk for latex sensitisation and allergy with life-threatening symptoms mostly during surgery. At the end of 1995 we initiated a primary latex prophylaxis around and during surgery and anaesthesia of all spina bifida patients. The aim of our study was to investigate the prevalence of latex sensitisation in the spina bifida patients born during the five years after establishing latex prophylaxis in the Cologne Children's Hospital in December 1995. We investigated 34 serum samples of 27 spina bifida patients (mean age 2.4 years) for specific IgE antibodies against latex allergens (CAP system) and compared these patients born after 1995 with 38 spina bifida patients up to 5 years of age (mean 3.1 years) born before. In the prophylaxis group two of 27 patients (7 %), one of them with two operations outside the Children's Hospital, had low specific IgE against latex (</= 0.9 kU/l, 3 and 5 operations). The other patients in this group were not sensitised despite up to 8 operations (min. 1, mean 3.1). In contrast, before introducing the prophylaxis, 16 of 38 patients (42 %) were latex IgE-positive after multiple operations (min. 2, max. 11, mean 4.7) with values of specific IgE up to > 100 kU/l (mean 22.6 kU/l, min 0.4 kU/l). Sera of 22 patients remained negative for latex IgE (min. 1, max. 19, mean 4.3 operations). By primary latex prophylaxis during surgery, anaesthesia and in paediatric wards the prevalence of latex sensitisation can be significantly reduced even in the high risk group of spina bifida patients. Problems can arise by the need for surgery in hospitals not experienced in the treatment of spina bifida patients, where latex prophylaxis is neglected.

Incidental and symptomatic renal tumors: impact on patient survival

CONTEXT

Renal cell carcinoma is the third most frequent genitourinary neoplasia, and there is currently an increase in the incidental diagnosis of tumors confined to the kidneys.

OBJECTIVE

To study the survival of patients with incidental and symptomatic renal tumors who have undergone nephrectomy.

DESIGN

Retrospective.

SETTING

Hospital Sírio Libanês and Hospital Beneficência Portuguesa de São Paulo.

PARTICIPANTS

115 patients with diagnosis of renal cell carcinoma, operated on by the same group of surgeons and evaluated by a single pathologist.

MAIN MEASUREMENTS

Sex, age and diagnosis method, analyzed in two groups, according to the tumor diagnosis: Group 1 with incidental diagnosis and Group 2 with symptomatic tumors. The anatomopathological characteristics and patient survival in both groups were evaluated. A statistical analysis was performed using the Student t, chi-squared, log rank and Kaplan-Meyer tests.

RESULTS

Among the studied patients, 59(51%) had an incidental diagnosis, with 78% diagnosed by ultrasonography, 20% by computerized tomography scan and 2% during surgeries; 56 patients (49%) were symptomatic. Tumor locations were equally distributed between the two kidneys, and the surgery was conservative for 24% of the incidental and 9% of the symptomatic group. In the incidental group only one patient had tumor progression and there was no death, while in the symptomatic group there were 5 progressions and 10 deaths. The 5-year specific cancer-free survival was 100% in the incidental and 80% in the symptomatic group (p = 0.001) while the disease-free rate was 98% in the incidental and 62% in the symptomatic group (p < 0001).

CONCLUSION

Incidental renal tumor diagnosis offers better prognosis, providing longer disease-free survival.

Vinorelbine in androgen-independent metastatic prostatic carcinoma--a phase II study

The purpose of this study was to evaluate the efficacy of vinorelbine treatment in terms of prostate-specific antigen (PSA) response and clinical benefit (decrease of pain or analgesic score for the subgroup of patients with pain), as well as its toxicity in patients with progressive metastatic androgen-independent prostatic carcinoma. 44 patients with prostatic carcinoma progressing after orchiectomy or during treatment with hormonal agents were treated with vinorelbine at a dose of 30 mg/m(2) intravenously (i.v.) on days 1 and 8 of a 21-day cycle. Inclusion criteria were metastatic progressive prostatic carcinoma with prostate-specific antigen (PSA) serum levels >/=3 x upper limit of normal, World Health Organization (WHO) performance status </=2, age <85 years and adequate bone marrow, liver and renal functions. Treatment was continued until progression or a maximum of 12 cycles. Treatment was delayed for a week if haematological toxicity grade >/=2 was observed on the day of scheduled vinorelbine administration. 9 patients received less than three cycles, 6 due to rapid tumour progression. Treatment at day 1 had to be delayed in 13.7% of 183 cycles. Treatment at day 8 had to be omitted in 19.7% of all cycles. Grade >/=3 granulocytopenia occurred in 18% of patients. 4 patients had severe constipation. In 7 patients (15.9%, Confidence Interval (CI) 6.6-30.1%), a PSA response (>/=50% reduction of PSA levels) was observed. Among 8 patients with measurable disease, 3 had partial remission and 1 no change. Median time to PSA progression in 43 assessable patients was 11.9 weeks (range 3-52 weeks). Median duration of PSA response was 14 weeks (9-30 weeks). Clinical benefit was seen in 7 of 31 cases (23%) with baseline pain, there was no association with PSA response. Vinorelbine is a fairly well tolerated drug with a moderate single agent activity in patients with androgen-refractory prostate cancer.

Microarrays of bladder cancer tissue are highly representative of proliferation index and histological grade

The number of genes suggested to play a role in cancer biology is rapidly increasing. To be able to test a large number of molecular parameters in sufficiently large series of primary tumours, a tissue microarray (TMA) approach has been developed where samples from up to 1000 tumours can be simultaneously analysed on one glass slide. Because of the small size of the individual arrayed tissue samples (diameter 0.6 mm), the question arises of whether these specimens are representative of their donor tumours. To investigate how representative are the results obtained on TMAs, a set of 2317 bladder tumours that had been previously analysed for histological grade and Ki67 labelling index (LI) was used to construct four replica TMAs from different areas of each tumour. Clinical follow-up information was available from 1092 patients. The histological grade and the Ki67 LI were determined for every arrayed tumour sample (4x2317 analyses each). Despite discrepancies in individual cases, the grade and Ki67 information obtained on minute arrayed samples were highly similar to the data obtained on large sections (p<0.0001). Most importantly, every individual association between grade or Ki67 LI and tumour stage or prognosis (recurrence, progression, tumour-specific survival) that was observed in large section analysis could be fully reproduced on all four replica TMAs. These results show that intra-tumour heterogeneity does not significantly affect the ability to detect clinico-pathological correlations on TMAs, probably because of the large number of tumours that can be included in TMA studies. TMAs are a powerful tool for rapid identification of the biological or clinical significance of molecular alterations in bladder cancer and other tumour types.

Microarrays of bladder cancer tissue are highly representative of proliferation index and histological grade

The number of genes suggested to play a role in cancer biology is rapidly increasing. To be able to test a large number of molecular parameters in sufficiently large series of primary tumours, a tissue microarray (TMA) approach has been developed where samples from up to 1000 tumours can be simultaneously analysed on one glass slide. Because of the small size of the individual arrayed tissue samples (diameter 0.6 mm), the question arises of whether these specimens are representative of their donor tumours. To investigate how representative are the results obtained on TMAs, a set of 2317 bladder tumours that had been previously analysed for histological grade and Ki67 labelling index (LI) was used to construct four replica TMAs from different areas of each tumour. Clinical follow-up information was available from 1092 patients. The histological grade and the Ki67 LI were determined for every arrayed tumour sample (4x2317 analyses each). Despite discrepancies in individual cases, the grade and Ki67 information obtained on minute arrayed samples were highly similar to the data obtained on large sections (p<0.0001). Most importantly, every individual association between grade or Ki67 LI and tumour stage or prognosis (recurrence, progression, tumour-specific survival) that was observed in large section analysis could be fully reproduced on all four replica TMAs. These results show that intra-tumour heterogeneity does not significantly affect the ability to detect clinico-pathological correlations on TMAs, probably because of the large number of tumours that can be included in TMA studies. TMAs are a powerful tool for rapid identification of the biological or clinical significance of molecular alterations in bladder cancer and other tumour types.

High-throughput tissue microarray analysis of 3p25 (RAF1) and 8p12 (FGFR1) copy number alterations in urinary bladder cancer

Studies by comparative genomic hybridization revealed that the chromosomal regions 3p25 and 8p11-p12 are recurrently amplified in bladder cancer. To investigate the prevalence of DNA copy number alterations in these chromosomal regions and study their clinical significance, we used probes for the RAF1 (3p25) and FGFR1 (8p12) genes for fluorescence in situ hybridization. A tissue microarray containing 2317 tumors was analyzed. The analysis revealed RAF1 amplification in 4.0% and FGFR1 amplification in 3.4% of interpretable tumors. In addition, deletions were found at the 3p25 locus in 2.2% and at the 8p11-12 locus in 9.9% of interpretable tumors. Both amplifications and deletions of RAF1 and FGFR1 were significantly associated with high tumor grade (P < 0.0001), advanced stage (P < 0.0001), and poor survival (P < 0.05) if tumors of all of the stages where analyzed together. RAF1 amplifications were associated with subsequent tumor progression in pT1 carcinomas (P < 0.05). The marked differences in the frequency of all of the analyzed changes between pTa grade 1/grade 2 and pT1-4 carcinomas support the concept of these tumor groups representing different tumor entities.

Response and palliation in a phase II trial of gemcitabine in hormone-refractory metastatic prostatic carcinoma. Swiss Group for Clinical Cancer Research (SAKK)

BACKGROUND

In a phase II trial, 43 patients with hormone-refractory prostate cancer were treated with gemcitabine at a dose of 1,200 mg/m2 over 2 hours (later decreased to 1,000 mg/m2 due to hematological toxicity) on days 1, 8 and 15 of a 28 day cycle.

PATIENTS AND METHODS

Inclusion criteria were proven tumor progression after hormonal treatment and increased PSA levels, a WHO PS < or = 2, adequate bone marrow reserve, liver and renal function and age < or =, 80 years. Response criteria were based on PSA levels (CR: normalization of PSA, PR: > 50% decrease). Quality of life (QL) was assessed with the EORTC QLQ-C30 on day 1 of each treatment cycle and on day 8 of the first cycle (range of scales 0-100). Physician-rated pain intensity and use of pain medication were assessed at the same timepoints.

RESULTS

Hematological toxicity of gemcitabine led to a dose-reduction in 48% of all cycles. Three of forty-three patients (RR = 7%) showed a PSA response: one CR and three PR with time to treatment failure of 8.7, 6.6 and > or = 9.3 months. Seven patients (16%) had stable disease (NC) for a median duration of 7.1 months (range 6.1-11.7 months). There was one case with objective regression of lymph node metastases. Patients reported a considerably impaired health status/QL (n = 41, median = 50) and severe fatigue (n = 41, median = 55.6) at baseline, with no change under treatment. Pain (QLQ-C30) was also severe at baseline (N=41, median=50) but was improved at the end of cycles 1 (n = 33, median change = -16.7, P = 0.0002), 2 (n = 19, median change = -33.3, P = 0.0006), 3 (n = 14, median change = -16.7, P = 0.06) and 4 (n = 9, median change = -33.3, P = 0.04). Patient-rated pain and use of analgesics as combined endpoint yielded palliation for at least 8 weeks in 14 patients (32%). Nine of these patients showed at least stable disease (CR/PR or NC by PSA level), five indicated a benefit in spite of progressive disease.

CONCLUSIONS

Gemcitabine in the dose and schedule indicated above has a significant beneficial impact on pain in patients with hormone-refractory prostatic carcinoma despite its limited activity in terms of PSA response and considerable, especially hematological, toxicity.

Transitional cell carcinoma of the vagina with pagetoid spread pattern

A distinctive variant of a papillary noninvasive transitional cell carcinoma (TCC) of the vagina removed from a postmenopausal woman is described. The neoplasm was evaluated by immunohistochemistry. The designation of this neoplasm as a TCC is supported by its morphological features and its coexpression for cytokeratin (CK) 7 and CK 20. Its main feature is pagetoid infiltration into adjacent vaginal epithelium. This is the second reported case involving a transitional cell metaplasia (TCM) of the vagina, a possible precursor lesion of the TCC.

A phase II study of oral idarubicin as a treatment for metastatic hormone-refractory prostate carcinoma with special focus on prostate specific antigen doubling time. Swiss Group for Clinical Cancer Research, Berne, Switzerland

BACKGROUND

Treatment of hormone-refractory prostate carcinoma with chemotherapy is purely palliative, and reported response rates have been low. At the time this study was conducted, there was an urgent need for a trial using potentially efficacious drugs, with quality of life (QL), and serial prostate specific antigen (PSA) behavior as endpoints.

METHODS

In this Swiss multicenter Phase II study, 30 patients were enrolled to receive oral idarubicin. Patients were administered 35 mg idarubicin on Days 1 and 8 of each cycle, and treatment was repeated every 3 weeks. Assessment was based on response rates, sequential PSA measurements in serum, toxicity, and selected aspects of QL.

RESULTS

Twenty-six of 30 patients were evaluable for response, and none of them achieved a response. Three patients had stable disease as their best response, and their PSA levels also remained stable. In all other patients, PSA increased exponentially over time; the median PSA doubling time was 2.1 months (mean, 2.6; range, 0.7-6.1). Toxicity was minimal and consisted mainly of myelosuppression and nausea/vomiting. QL did not change significantly during therapy with regard to general well-being, fatigue, or nausea/vomiting. However, there were improvements in patient-rated and physician-rated pain.

CONCLUSIONS

At the dose and schedule used in this study, oral idarubicin showed only minimal efficacy against hormone-refractory prostate carcinoma. In patients who did not respond, PSA doubling times were similar to those in patients who relapsed while receiving only antiandrogen therapy. In future clinical trials, QL and serial PSA behavior should be included in analysis.

Impact of minimal lymph node metastasis on long-term prognosis after radical prostatectomy

OBJECTIVES

In the management of clinically localized prostate cancer, understanding is of major concern. There is a considerable therapeutic dilemma in those patients in whom staging lymphadenectomy prior to intended radical prostatectomy reveals lymph node metastases.

METHODS

Pelvic lymph node dissection and radical retropubic prostatectomy were performed in 132 consecutive patients. Patients with extracapsular disease and/or positive lymph nodes received adjuvant radiotherapy. Median follow-up after surgery was 7 years and 2 months. To study the influence of minimal lymph node metastasis, category pN1 was further subdivided into pN1.1 and pN1.2. Involvement of the prostatic capsule was either classified as infiltration (pT3.1) or performation (pT3.2) of the capsule.

RESULTS

Disease-free survival after 10 years was 58% in patients with negative nodes, 37% in category pN1.1, 25% in category pN1.2 and 10% in category pN2. Corrected overall survival was 83% for node-negative patients and 73% for category pN1.1, but it was only 33% for pN1.2 and 29% for pN2. Patients in category pT3.1 had a statistically significant better survival than those in pT3.2.

CONCLUSIONS

We conclude that radical prostatectomy combined with adjuvant radiotherapy is a valuable option in prostate cancer patients with minimal lymph node metastasis. When compared to infiltration of the capsule, complete capsular perforation does adversely affect prognosis.

Isoelectric focusing of Tamm-Horsfall glycoproteins: a simple tool for recognizing recurrent calcium oxalate renal stone formers

Tamm-Horsfall glycoproteins (THPs) from healthy probands and a majority of recurrent calcium oxalate renal stone formers reveal different physicochemical properties when analyzed using isoelectric focusing (IEF). The pI values of THPs from healthy probands are approximately 3.5 while THPs from recurrent renal stone formers have pI values of between 4.5 and 6. The two groups of THPs exhibit completely different protein patterns. The differences in IEF analysis allow differentiation between THPs from healthy probands and recurrent calcium oxalate stone formers and may possibly be used as a simple diagnostic method for the recognition of recurrent calcium oxalate renal stone formers.

Intracytoplasmic sperm injection (ICSI) with testicular sperm extraction (TESE) in non-obstructive azoospermia--two case reports

Intracytoplasmic sperm injection (ICSI) with microsurgical epididymal sperm extraction (MESA) or testicular sperm extraction (TESE) can be offered to azoospermic men. We report our initial experience of two cases with ICSI-TESE in non-obstructive azoospermia. Both couples had a successful ICSI with embryo transfer. An ongoing triplet pregnancy at 21 weeks is observed.

Tamm-Horsfall glycoprotein: role in inhibition and promotion of renal calcium oxalate stone formation studied with Fourier-transform infrared spectroscopy

Tamm-Horsfall glycoprotein (THP) from healthy probands inhibits the precipitation of calcium oxalate, whereas THP from individuals who repeatedly develop calcium oxalate stones has no effect or even promotes precipitation. Using Fourier-transform infrared spectroscopy, we found a structural differentiation between these functionally different THPs: a decisive difference in sialic acid content. Quantitative analysis for sialic acid showed the same results. THP from healthy probands had a high sialic acid content (51 +/- 9 g/kg), whereas THP from recurrent stone formers had a decreased sialic acid content (21 +/- 4 g/kg). This explains the dual role of THP in the precipitation of calcium oxalate and the formation of renal stones and shows the importance of glycosylation in the function of this glycoprotein.

Tamm-Horsfall glycoprotein: role in inhibition and promotion of renal calcium oxalate stone formation studied with Fourier-transform infrared spectroscopy

Tamm-Horsfall glycoprotein (THP) from healthy probands inhibits the precipitation of calcium oxalate, whereas THP from individuals who repeatedly develop calcium oxalate stones has no effect or even promotes precipitation. Using Fourier-transform infrared spectroscopy, we found a structural differentiation between these functionally different THPs: a decisive difference in sialic acid content. Quantitative analysis for sialic acid showed the same results. THP from healthy probands had a high sialic acid content (51 +/- 9 g/kg), whereas THP from recurrent stone formers had a decreased sialic acid content (21 +/- 4 g/kg). This explains the dual role of THP in the precipitation of calcium oxalate and the formation of renal stones and shows the importance of glycosylation in the function of this glycoprotein.

Investigations on macromolecular precipitation inhibitors of calcium oxalate

Certain important aspects of the urine oxalate tolerance test (OTT) have been revised. The stirring system has been changed and the test has been adapted to the kinetics of calcium oxalate precipitation. True equilibrium conditions are now ensured during the measurements. Furthermore, the endogenous oxalate concentration is determined and taken into consideration. As a result of these changes, the significance of the test results has greatly improved. The effects of the addition of small amounts of zinc on the precipitation of calcium oxalate have been used in a new variation of the OTT. This new test makes it possible to discriminate much faster and more simply between recurrent stone-formers and other subjects. Tamm-Horsfall protein (THP) has been tested for its effect on the precipitation of calcium oxalate by means of OTT. THP inhibits the precipitation of calcium oxalate, but THP of stone-formers has a diminished inhibitory activity. The inhibitory activity of this protein strongly depends on the method by which it is isolated.

31P MR spectroscopy and 1H MR imaging of the human prostate using a transrectal probe

1H magnetic resonance imaging and 31P magnetic resonance spectroscopy of the human prostate using transrectal surface coils are discussed. 1H MR images were characterized by a high sensitivity, revealing many details in the prostate. Localized 31P spectra acquired during the same investigation showed phosphorous metabolites, which may help differentiate between benign prostatic hyperplasia and prostate carcinoma. An endoscopic transmit-receive radio frequency (RF) antenna is also described which can be used with very low RF power.

[Primary extragonadal choriocarcinoma of the bladder. A case report with a compilation of the 19 cases published so far]

We report on a 73-year-old man with a primary extragonadal choriocarcinoma of the urinary bladder associated with transitional cell carcinoma. So far only 19 cases of choriocarcinoma of the bladder have been published in the literature. With reference to the cases reported in the English literature, the relationships between serum beta-HCG level, mode of therapy and clinical course are pointed out. Finally, the possible explanations for pathogenesis are discussed and the signs and symptoms that are mandatory for diagnosis of this entity are defined.

Does microinvasion of the capsule and/or micrometastases in regional lymph nodes influence disease-free survival after radical prostatectomy?

Since 1976, 126 patients with clinically localised carcinoma of the prostate have been managed by radical retropubic prostatectomy. All patients with tumour spread beyond the capsule or metastasis in lymph nodes received radiotherapy. Tumour category pT3 was divided into invasion of the capsule or infiltration of the seminal vesicle. The disease-free 10-year survival rate in patients with minimal invasion of the capsule was 72% and in patients with infiltration of the seminal vesicles it was 26%. Unilateral lymph node metastases were classified as microscopic disease or macroscopic infiltration. The disease-free 10-year survival rate in patients with metastasis in 1 lymph node (micro- and macro-metastasis) was 65% in contrast to 0% in patients with bilateral disease.

[Prevention of urinary calculi in spite of painless lithotripsy?]

Localization, stone-size as well as type of lithotriptors influence the extent of disintegration of stones and the individual rate free of stones after treatment with extracorporeal shock wave lithotripsy. The piezoelectric lithotriptors do not require anaesthesia, but perform insufficient stone disintegration requiring no repeated treatments. Another draw-back is stone localization by ultrasound, which prevents treatment of some ureteral stones. Used voltage and rate of shock waves per treatment affect the extent of damage no the renal parenchyma. Risk of hypertension, residual disintegrated stones, which don't clear the renal pelvis, the higher recurrency rate and injury to the urothelium of the renal pelvis demand a concomitant meta- and prophylaxis of urolithiasis.