Clinical value of transrectal ultrasound in the diagnosis of suspected neoplasia in the small pelvis

PURPOSE

In daily clinical practice, it is challenging to accurately diagnose suspected neoplasias in the small pelvis by minimal invasive means, and CT-guided biopsy is often limited in its feasibility. The aim of our study was to evaluate whether transrectal ultrasound (TRUS)-guided biopsy can verify suspected neoplasias in the small pelvis histologically.

MATERIAL AND METHODS

The study population consisted of 12 patients who underwent biopsy of suspected malignancy in the pelvis by TRUS. All patients had clinical signs of an advanced tumour stage and in all cases, biopsy utilising computerised tomography (CT scan) had been unsuccessful despite of a documented lesion on CT scan or magnetic resonance imaging. For the TRUS guided biopsy, a commercially available 3-dimensional 7.5-MHz-probe was used (Combison 530 D, GENERAL ELECTRIC, Milwaukee, USA). The probe was armed with an 18 G biopsy gun.

RESULTS

In all patients, the suspected lesion was easily detectable by TRUS, and tissue for verification of the malignant origin of the lesions could be collected under real-time TRUS with only 2 patients needing anaesthesia. The biopsy cores were of excellent quality and adequate for conclusive pathological diagnosis. 6 cases of lymph node metastases of a transitional cell carcinoma were detected. 1 case of extended node metastasis in prostate cancer, 1 paravesical manifestation of recurrent cervical cancer, 1 metastasis of a paravesically infiltrating colon cancer and 2 cases of paravesical metastases of a gastric cancer were also diagnosed. In one case, extragenital endometriosis could be diagnosed.

CONCLUSION

Based on our experience it can be stated that TRUS-guided biopsy is a reliable diagnostic tool for verification of the neoplastic origin of suspected masses in the small pelvis. In all cases with a history of unsuccessful CT guided biopsy, sufficient tissue cores for conclusive histology could be collected with our technique, and surgical exploration could be avoided. This technique is minimally invasive, without radiation exposure, well tolerated under analgesia, time efficient and cheap.

[Rational diagnostic and therapy of renal colic in the year 2005--what's new?]

The acute flank pain is the most frequent urological emergency. Patients with renal colic are usually treated in emergency care units or by their family doctors and require immediate diagnosis and treatment. Up to 10 % of the population is estimated to suffer from kidney colic at least once in their lifetime. Besides, renal colic can occur during pregnancy and childhood, which require special attention when deciding therapy. Differential diagnosis of acute flank pain contains a series of diseases which belong not only in the urological field but need adequate directly therapy. Particularly, these principles should give useful advice, wherever patients are treated without urological department.

Innovative Diagnostik in der Früherkennung und beim Staging des lokalisierten Prostatakarzinoms

Prostate cancer is the most common malignancy in males. Men aged 50 years and older are recommended to undergo an annual digital rectal examination (DRE) and determination of prostate-specific antigen (PSA) in serum for early detection. Fortunately, disease-specific mortality continues to decline as a result of advances in screening, staging, and patient awareness. However, about 30% of men with a clinically organ-confined disease show evidence of extracapsular extension or seminal vesicle invasion on pathological analysis. Consequently, there is a need for more accurate diagnostic tools for planning tailored treatment. A variety of modern imaging techniques has been implemented in an attempt to obtain more precise staging, thereby allowing for more detailed counseling, and instituting optimum therapy. This review highlights developments in prostate cancer imaging that may improve staging and treatment planning for prostate cancer patients.

[Complications of transrectal prostate biopsy. Determination of current status]

The procedure for prostate biopsy has undergone a dramatic change in the last 2 decades. The introduction of PSA into diagnostics for prostate carcinoma and simultaneous development of modern biopsy techniques have led to a marked increase in transrectal prostate biopsies. At the same time, serious complications have become less frequent. Grave complications after biopsy include septic complications (approximately 1%), rectal hemorrhages (approximately 0.1%), and ischurias (0.5%). Less severe complications such as occurrence of fever without septic signs account for 3.5%. One of the frequent complications that usually do not require treatment is gross hematuria, which is observed in nearly 50% of all patients. The same applies to hematospermia with a similar frequency.In the rare cases of the altogether serious complications after prostate biopsy, appropriate action is essential. All in all, prostate biopsy nowadays represents a safe diagnostic procedure with few complications and an extraordinarily high level of usefulness for everyday urological practice.

Transvaginal bone anchors in female stress urinary incontinence: poor results

OBJECTIVE

This study evaluates the results of a minimally invasive technique for correcting female stress urinary incontinence by transvaginal implantation of pubic bone anchors.

PATIENTS AND METHODS

Female stress urinary incontinence was treated by fixing a gelatin-coated Dacron sling between two miniature titanium anchors with Prolene sutures.

RESULTS

A total of 26 patients (median age 57.2 years) underwent the sling procedure. The follow-up examination was performed after 11.4 months on average. Stress incontinence showed a median improvement from grade 2 to grade 0.5 (p = 0.01), although only 16 of the 26 patients were completely continent. Urethral pressure and functional length were not significantly influenced. Impaired vaginal wound healing was seen in 14 of the 26 patients (53.8%), and 13 of them underwent revision. All patients affected (15/26, 57.7%) as well as 1 with uneventful healing showed sensory urge symptoms or detrusor instability (7/26, 26.9%). The correlation between impaired wound healing and detrusor instability was highly significant (p < 0.003). 17 of the 26 patients (65.3%) were dissatisfied or very dissatisfied with the intervention. The unfavorable results did not significantly correlate with the patients' age, the number of previous operations, or the surgeon's skill.

CONCLUSION

In view of the poor vaginal wound healing and the resultant irritative symptoms, transvaginal bone anchoring with fixation of a Dacron sling must be regarded as an unsuitable technique.

[Remarks on the introduction of the German Diagnosis-Related Groups (DRGs) for the specialty of urology]

In January 2003 a new system to charge inpatient treatment was established in Germany: the G-DRGs. This system is based on the thought that equal medical service causes equal costs all over Germany. Hospitals offering a broad spectrum of diagnostics and therapies and being unable to select their patients according to economical aspects are put at disadvantage: Despite a perfect documentation the G-DRGs reflect their medical service only in an insufficient way. Tools for an optimized coding must be a coding manual created for the specific needs of urologists and an infrastructure that allows a permanent quality control for all persons involved.

Genetic changes in stage pT2N0 prostate cancer studied by comparative genomic hybridization

OBJECTIVE

To identify chromosomal regions important for progression in clinically organ-confined prostate cancer, as the genetic changes underlying the development and progression of prostate cancer are poorly understood.

MATERIALS AND METHODS

Comparative genomic hybridization (CGH) was used to search for DNA sequence copy-number changes in a series of 50 primary organ-confined prostate adenocarcinomas (pT2N0) removed by radical prostatectomy.

RESULTS

CGH analysis indicated that 23 (46%) of the primary prostate adenocarcinomas showed chromosome alterations. The percentage of tumours with losses (38%) was higher than with gains (28%). Losses of 13q (24%), 8p (18%), 6q (10%), 16q (8%), 18q (6%) and 5q (6%) and gains of 17q (12%), 20q (12%), 9q (10%), 17p (8%) and 8q (6%) were the most frequent alterations. Amplifications were found at 8q24-qter. Minimal overlapping regions of loss, indicative of the presence of tumour-suppressor genes, were mapped to 13q21.1-q21.3 and 8p21.2, and minimal overlapping regions of gain, indicative of the presence of oncogenes, were found at 9q34.4-qter, 17q25-qter and 20q13.3-qter. There was a significant association between Gleason score and losses and gains (P = 0.003), and an association between chromosomal imbalance and high histological grade (P = 0.008).

CONCLUSION

These results suggest that losses or gains of DNA in these regions are important for prostate cancer progression, and document the spectrum of chromosomal alterations in stage pT2N0 of clinically organ-confined prostate cancer.

[Prostatectomy, brachytherapy, percutaneous irradiation. Which method helps your patients the most?]

For the treatment of cancer of the prostate that has not yet metastasized, several therapeutic options that promise lasting local tumour control are now available: Among the surgical options, radical retropubic prostatectomy is most commonly employed. The basic radiotherapeutic options are interstitial and external beam irradiation, or a combination of the two. The choice of the most suitable therapeutic approach is determined by the extent of the tumor, and the side effects that are acceptable to the patient.

Prepubertal high flow priapism: incidence, diagnosis and treatment

PURPOSE

We reviewed the literature of the last 40 years and report our experience with treating high flow priapism with fistula embolization in prepubertal boys.

MATERIALS AND METHODS

Two boys had blunt perineal trauma and 1 had penile trauma (ages 6, 6 and 10 years). Painless priapism developed within 24 hours and lasted for 4 to 7 days before the patients presented to the hospital. Primary diagnosis was made on color Doppler ultrasound. When high flow priapism was diagnosed angiography of the internal iliac artery and embolization of the arteriocavernosal fistula were performed. Mean followup was 26 months.

RESULTS

Color Doppler ultrasound revealed bilateral arteriocavernosal fistulas in 2 boys and a unilateral fistula in 1. Angiography showed fistulas of the branches of the internal pudendal artery in 2 patients and fistulas of the bulbourethral artery in 1. Microcoils were used in the bulbourethral artery and a gelatin sponge was used in other penile arteries. Complete detumescence with restored erectile function was achieved in all cases.

CONCLUSIONS

High flow priapism in children can be diagnosed easily by typical clinical features combined with color Doppler ultrasound. In children with posttraumatic priapism embolization of the arteriocavernosal fistula is superior to surgical or medical procedures and should be the first line therapy. Embolization using microcoils for bulbourethral arteries and a gelatin sponge for other penile arteries has proved to be safe and successful therapy.

[Improvements in surgical therapy of incontinence--failed outcome!]

The general advances made in minimal invasive surgery in the last 15 years has also led to the introduction of several new techniques for treating female incontinence. In the further development of bladder neck suspension according to Stamey-Pereyra, the use of miniature bone anchors received considerable support. Bladder neck suspension according to Stamey-Pereyra yields good initial results with a low complication rate but achieves permanent continence in only 40-71%. The anterior percutaneous implantation of miniature bone anchors with the attached suspension effects continence rates between 24% and 94%. Healing rates for transvaginal application of miniature bone anchors range from 52% to 100%. Reactions to foreign bodies are particularly common with synthetics but also occur with autologous materials. They are often associated with detrusor instability or sensory urge symptoms. Though these minimally invasive techniques can reduce the severity of stress incontinence, long-term healing is only achieved in about half the cases. The techniques described appear to be particularly unsuitable for treating grade III stress incontinence. The morbidity is unacceptable, especially when synthetic material is used in combination with bone anchors. Impaired vaginal wound healing often occurs in conjunction with irritative symptoms.

Prediction of postoperative prostatic cancer stage on the basis of systematic biopsies using two types of artificial neural networks

OBJECTIVE

The choice of therapy for prostatic cancer should depend on a rational preoperative estimate of tumor stage. Artificial neural networks were used to predict postoperative staging of prostatic cancer from sextant biopsies and routinely available preoperative data.

METHODS

In group I (97 cases), nonorgan confinement (tumor stage > or =pT3a) was predicted on the basis of age and six histopathological variables from sextant biopsies. In group II (77 cases), nonorgan confinement and extraprostatic organ infiltration (tumor classification > or =pT3b) were predicted from age, four histopathological variables, the preoperative PSA level, and the total prostate volume estimated by preoperative ultrasonography. Learning vector quantization (LVQ) networks were applied for this purpose and compared to multilayer perceptrons (MLP) and linear discriminant analysis (LDA).

RESULTS

Nonorgan confinement could be predicted correctly in 90% of newly presented cases from sextant biopsy histopathology alone. A similar accuracy of predicting nonorgan confinement (83%) was obtained by combining preoperative biopsy histology with clinical data. Extraprostatic organ infiltration could be predicted correctly in 82%. The best results were obtained by LVQ networks, followed by MLP networks and LDA.

CONCLUSION

The postoperative tumor stage of prostatic cancer can be estimated with high accuracy, sensitivity and specificity from preoperative routine parameters using artificial neural networks, especially LVQ networks. The results suggest that this methodology should be evaluated in a larger prospective study.

[Diagnosis of vesico-intestinal fistulas by contrast medium enhanced 3-D ultrasound]

AIM

Standard diagnostic tools for vesico-intestinal fistulas are cystoscopy, cystography, colonoscopy, and contrast enema. The aim of our study was to evaluate the efficacy of transrectal 3D-ultrasound with contrast media in these patients.

METHOD

From 5/98 to 12/99 we examined 10 patients with symptoms of a vesico-intestinal fistula (pneumaturia, faecaluria). After placement of a transurethral catheter a transabdominal ultrasound examination (Kretz Combison 530) was performed with the bladder half full to evaluate the bladder wall. Then the bladder was filled with diluted ultrasound contrast media (Levovist 40 mg/ml) to visualize the flow from the bladder towards the fistula. To verify a flow through the bladder wall a colour Doppler sonography of the region of interest was added. To evaluate form and extent of the fistula a transrectal ultrasound with 3D-image assessment was performed.

RESULTS

Using this technique it was possible to demonstrate a vesico-intestinal fistula in 9 of 10 patients. In all cases these findings were confirmed by the standard diagnostic procedures. The fistulas were caused by: bladder carcinoma (n = 1), carcinoma of the colon (n = 2), Crohn's disease (n = 3) and diverticulitis of the sigma (n = 3). One patient presented with a neovesico-intestinal fistula in an irradiated local recurrence of bladder carcinoma. In one patient with Crohn's disease whose only symptom was pneumaturia all diagnostic tools failed to provide the diagnosis.

CONCLUSION

For the first time vesico-intestinal fistulas could be demonstrated by ultrasound with 3D-image assessment using contrast media. This technique might be an effective addition to the standard diagnostics of vesico-intestinal fistulas reducing the exposure to radiation.

Orthotopic ileal neobladder in females: impact of the urethral resection line on functional results

We present our functional experience with orthotopic bladder replacement in female patients dependent on the urethral resection line. Between November 1986 and July 1998 42 women underwent orthotopic urinary tract reconstruction with an ileal neobladder at our institution: 26 patients underwent radical cystectomy (RCx) with subsequent ileal anastomosis to the urethra, and 16 underwent simple cystectomy (SCx) with preservation of the bladder neck. Fourteen of 22 patients following RCx and 3 of 14 patients following bladder neck-sparing cystectomy void naturally. Clean intermittent catheterization is necessary in 8 of 22 and 11 of 14 patients, respectively. Perfect continence with no pads at 1 year postoperatively was achieved in 15 of 18 evaluable patients following RCx and 10 of 11 patients following bladder neck sparing. Incontinence requiring one or more pads is present in 3 of 18 patients and 1 of 11 patients, respectively. Subjectively satisfactory continence was achieved in 16 of 18 patients following RCx and in all patients following bladder neck-sparing surgery. Our conclusions are that radical cystectomy as well as a bladder neck-sparing cystectomy does provide satisfactory functional results in the majority of patients. However, the urethral resection line does slightly influence the rate of incontinence as well as the requirement for intermittent catheterization. RCx does translate into a lesser requirement for CIC, whereas bladder neck sparing results in slightly better continence rates.

Cluster analysis of comparative genomic hybridization (CGH) data using self-organizing maps: application to prostate carcinomas

Comparative genomic hybridization (CGH) is a modern genetic method which enables a genome-wide survey of chromosomal imbalances. For each chromosome region, one obtains the information whether there is a loss or gain of genetic material, or whether there is no change at that region. Usually it is not possible to evaluate all 46 chromosomes of a metaphase, therefore several (up to 20 or more) metaphases are analyzed per individual, and expressed as average. Mostly one does not study one individual alone but groups of 20-30 individuals. Therefore, large amounts of data quickly accumulate which must be put into a logical order. In this paper we present the application of a self-organizing map (Genecluster) as a tool for cluster analysis of data from pT2N0 prostate cancer cases studied by CGH. Self-organizing maps are artificial neural networks with the capability to form clusters on the basis of an unsupervised learning rule, i.e., in our examples it gets the CGH data as only information (no clinical data). We studied a group of 40 recent cases without follow-up, an older group of 20 cases with follow-up, and the data set obtained by pooling both groups. In all groups good clusterings were found in the sense that clinically similar cases were placed into the same clusters on the basis of the genetic information only. The data indicate that losses on chromosome arms 6q, 8p and 13q are all frequent in pT2N0 prostatic cancer, but the loss on 8p has probably the largest prognostic importance.

Colour Doppler ultrasound in vesicovaginal fistulas

The purpose was to evaluate the feasibility of diagnosing vesicovaginal fistulas by colour Doppler ultrasound with contrast media. Twelve consecutive patients were examined by vaginoscopy, methylene blue test, cystogram and cystoscopy. For ultrasound examination, the bladder was filled with saline. Then diluted contrast media (Levovist) was instilled. Colour Doppler ultrasound revealed a jet phenomenon through the bladder wall toward the vagina, proving the existence of the fistula. Eleven patients had vesicovaginal fistulas, one patient a vesicoureterovaginal fistula. Colour Doppler ultrasound had correct results in 11 of 12 patients (92%). In follow-up examinations of four patients during a prolonged drainage of the bladder, we could correctly demonstrate the closure of one fistula. Colour Doppler ultrasound with contrast media is a new useful diagnostic tool in the evaluation and follow-up of vesicovaginal fistulas. It is less invasive than cystoscopy and needs no radiation exposure. The examination is well tolerated by the patients.

Prediction of prostatic cancer progression after radical prostatectomy using artificial neural networks: a feasibility study

OBJECTIVE

To report a methodological feasibility study in a small series of patients with node-negative organ-confined prostatic cancer, using artificial neural networks to predict tumour progression after radical prostatectomy and thus help to identify high-risk patients who would benefit from adjuvant treatment.

PATIENTS AND METHODS

A group of 20 patients with pT2N0 prostatic cancer and postoperative tumour progression was compared with a control group of 20 patients with no progression, matched for age, duration of follow-up and preoperative serum prostate-specific antigen level. Histopathological data were obtained from the radical prostatectomy specimens, i.e. the Gleason score, World Health Organisation (WHO) grade and maximum diameter of the tumour transects. The volume and surface area of the epithelial tumour component and of the lumina of the neoplastic glands per unit tissue volume were estimated by morphometric methods. To predict recurrence, multilayer feedforward networks with backpropagation (MLFF-BP), two implementations of learning vector quantization (LVQ), and linear discriminant analysis (LDA) were applied. The ability of these models to correctly classify new cases was tested using the 'leave-one-out' technique.

RESULTS

Progression was predicted correctly in 85% of newly presented cases from the three routine histopathological variables alone. On the basis of the four morphometric variables alone progression was predicted correctly in 93% of cases. The use of all seven variables as input data only slightly improved the quality of prediction. The best results were obtained by the LVQ networks and LDA, followed by MLFF-BP networks.

CONCLUSIONS

In this methodological feasibility study, the progression of pT2N0 prostatic cancer after radical prostatectomy could be predicted with good accuracy, sensitivity and specificity from routine variables or morphometric texture variables using artificial neural networks. These results suggest that this approach should be assessed in a prospective study with more cases.

[3D endosonography to clarify distal ureteral processes]

PURPOSE

Evaluation of 3D endoluminal sonography as a diagnostic modality in lower ureteral pathologies.

MATERIALS AND METHODS

Between December 93 and December 97, 36 consecutive patients with negative findings on IVP and still suspected ureteral obstruction were referred for transrectal or transvaginal endosonography. Patients mean age was 63 years and all of them presented clinically obvious symptoms such as colic pain and miction disturbances.

RESULTS

In 31 of 36 patients (86%) 3D endosonography was diagnostic although previous IVP was negative. Reasons for ureteral obstructions were ureteral calculi in 23, urological tumours in 5 and rectal carcinoma in two cases. In one patients a gynecological tumour caused the symptomatology. In the remaining 5 patients CT/MRT or invasive retrograde ureterography/ureteroscopy had to be performed for the final diagnosis.

CONCLUSIONS

The use of 3D endosonography shows encouraging results in the diagnosis of distal ureteral pathologies. In case of negative findings on IVP it should therefore precede invasive diagnostic modalities or cost intensive imaging techniques.

Serum half-life time determination of free and total prostate-specific antigen following radical prostatectomy--a critical assessment

OBJECTIVES

All studies investigating the elimination kinetics of serum total (tPSA) and free (fPSA) prostate-specific antigen (PSA) were carried out in men undergoing radical prostatectomy. Radical prostatectomy itself could, however, have a major influence on the serum concentration of these tumor markers (e.g., perioperative fluid shift or blood loss). The purpose of our study was to determine the half-life time of fPSA and tPSA with special regard to the influence of the radical prostatectomy on the serum concentration of these tumor markers.

METHODS

Eleven men (mean age 63.2+/-7.2 years) with organ-confined prostate cancer who underwent radical prostatectomy were investigated (final pathologic Stage pT2pN0 or lower). Serum samples were obtained preoperatively and 0.25, 0.5, 1, 2, 4, 8, 12, 16, 24, 48, 72, 120, 168, and 240 hours after removal of the prostate. fPSA and tPSA and albumin and total protein serum concentrations were determined in all samples.

RESULTS

During the first 120 minutes after removal of the prostate, albumin and total protein serum concentrations continuously declined, with a half-life time of -104.5+/-28 minutes and -129.7+/-32 minutes, respectively. Serum decline of fPSA and tPSA followed a biphasic kinetic. During the initial alpha-phase, fPSA and tPSA serum concentrations decreased, with a half-life time of -69+/-10.3 minutes and -87.3+/-18.1 minutes, respectively. During the terminal beta-phase, the half-life time of fPSA and tPSA was -1152.2 minutes (0.8 days) and -3916.1 minutes (2.7 days), respectively. Between the alpha-phase half-life time of fPSA or tPSA and the half-life time of the total protein or albumin concentration decline, significant correlations were found.

CONCLUSIONS

These correlations indicate that the rapid decline of fPSA and tPSA directly after removal of the prostate (alpha-phase half-life time) is caused by the radical prostatectomy itself. The half-life time of the beta-phase reflects the biologic clearance of PSA. Therefore, the half-life time determination of PSA after radical prostatectomy is of limited value if the influence of the operation itself on the serum PSA concentration is not taken into account.

The ileal neobladder: complications and functional results in 363 patients after 11 years of followup

PURPOSE

Since 1986 orthotopic lower urinary tract reconstruction using the ileal neobladder has been our diversion of choice in patients of both sexes undergoing cystectomy. We report on experience and functional results of the first 363 men 11 years after this procedure.

MATERIALS AND METHODS

Complications were assessed, tabulated, subdivided into early (3 months or less postoperatively) and late types, and further categorized with respect to relationship to neobladder construction. Continence and voiding pattern were individually evaluated via a detailed patient questionnaire.

RESULTS

Perioperative death occurred in 11 patients (3%). Neobladder related early and late complications occurred in 56 (15.4%) and 85 (23.4%) of the 363 patients, respectively. Neobladder related early and late abdominal reoperation rates were 0.3 and 4.4%, respectively. Perioperative neobladder unrelated early complications were observed in 122 patients (33.6%) and 44 (12.1%) required operative treatment. Late postoperative complications unrelated to the neobladder occurred in 45 patients (12.4%) and 19 required open surgical revision. Of 290 evaluable patients 96.1% void spontaneously, 3.9% perform clean intermittent catheterization in some form and 1.7% perform regular intermittent catheterization. Daytime and nighttime continence was reported as good by 95.9% and satisfactory by 95% of the patients. Unacceptable daytime continence requiring more than 1 pad per day occurred in only 4.1% of the patients and only 5% are wetting more than 1 pad a night.

CONCLUSIONS

The ileal neobladder produces good functional results and can be constructed with acceptable complications. Our data suggest that although it is not a complication-free procedure, we advocate its use when possible.

[The percutaneous transarterial embolization therapy of traumatic kidney hemorrhages]

PURPOSE

To demonstrate the possibility of transarterial, superselective embolization after traumatic kidney injury and hemorrhage in patients usually treated by surgery.

METHODS

In a series of 16 patients aged 21 to 86 years (mean 37 years) external trauma led to kidney damage and consecutive bleeding. After diagnostic angiography (5 F) the exact site of hemorrhage was detected and treated by superselective embolization via a coaxial catheter system (2.7 F) either by coils (n = 5) or liquid agents (ethibloc, n = 11).

RESULTS

In all patients bleeding was stopped interventionally. Additional surgical treatment was not necessary in any case. In one older patient with preinterventionally known reduced kidney function, the excretion function decreased to creatinine levels of about 3.6 mg/dl after therapy and led to compensated nephric insufficiency. Other complications were not observed.

CONCLUSION

Interventional embolization is a well-tolerated and effective treatment modality after traumatic kidney hemorrhage. After exclusion of other injuries obligate for surgery, percutaneous transarterial therapy may help to avoid an operation. This reduces the risk of narcosis and treatment especially in multimorbid patients.

Virtual cystoscopy based on helical CT scan datasets: perspectives and limitations

The purpose of the study was to simulate cystoscopy based on three-dimensional helical CT scan datasets in real-time in patients with tumours of the urinary bladder. A helical CT scan with double detector technology was carried out pre-operatively in 11 patients with histologically confirmed carcinoma of the urinary bladder and one patient with chronic cystitis. A non-enhanced scan was first performed, followed by an examination in the early phase of contrast medium enhancement. Further images were acquired after adequate filling of the bladder with contrast medium, approximately 30 min after injection. These data were transferred to a separate graphic computer workstation and reconstructed. The results were then compared with the cystoscopic and histopathological findings. All tumours of the urinary bladder identified at fibreoptic cystoscopy were shown on virtual cystoscopy. The best reconstruction results were obtained from data acquired 30 min after injection of contrast medium. The ureteric orifices were not visualized at virtual cystoscopy. These data lead us to conclude that, at present, virtual cystoscopy has not reached the quality of fibreoptic examination and remains restricted to use in specific cases, for example patients with urethral strictures.

Treatment of high-risk patients with subvesical obstruction from advanced prostatic carcinoma using a thermosensitive mesh stent

OBJECTIVE

To evaluate the results obtained using a permanent prostatic stent system (Memotherm, Bard/ Angiomed, Karlsruhe, Germany) in high-risk patients with advanced prostatic carcinoma and subvesical obstruction.

PATIENTS AND METHODS

The study included 35 patients (mean age 75.3 years, range 53-89) with advanced prostatic carcinoma and persistent subvesical obstruction despite androgen ablation. Because of serious concurrent diseases, 49% of these patients were classified as American Society of Anesthesiologists (ASA) grade 3 and 51% as ASA grade 4. The patients were treated using the Memotherm stent, a thermosensitive Nitinol mesh stent. The outcome was assessed by measuring voiding variables, a symptom score and as the incidence of complications.

RESULTS

After inserting the stent, 33 (94%) of the patients were able to void spontaneously and there was a statistically significant improvement in the voiding variables. These results remained unchanged over a mean (range) follow-up of 15.2 months (3-38). There were no serious complications arising from the insertion of the stent.

CONCLUSION

For high-risk patients with subvesical obstruction caused by prostatic carcinoma, the insertion of a permanent metal stent system offers a useful alternative treatment to transurethral resection.

Sensitivity of computed tomography in detecting local recurrence of prostatic carcinoma following radical prostatectomy

The aim of this study was to evaluate CT imaging in the post-operative follow-up and in the detection of recurrence after radical prostatectomy in cases of prostatic carcinoma. In over 500 patients undergoing radical prostatectomy for prostatic carcinoma, 22 cases with local recurrence were found. CT examinations of the pelvis were retrospectively evaluated in these patients. Local recurrence was detected by PSA uptake and confirmed by transrectal ultrasound (TRUS) in combination with guided biopsy. In 22 cases of confirmed local recurrence, positive results on CT were found in eight patients (36%) and negative results in nine patients (41%). In the remaining five cases (23%), no distinction could be made between scar and local recurrence. All cases definitively classified as recurrent tumour disease showed a soft tissue mass of 2 cm or more. CT sensitivity in local recurrence of prostatic carcinoma after surgery is low. Even in a very careful follow-up, the understaging would be up to 41%. In comparison, PSA, TRUS and needle biopsy are the methods of choice and are superior to CT imaging. Based on these results, there would be no reason for including pelvic CT examinations in the follow-up of prostatic carcinoma after radical prostatectomy.

[Transurethral collagen injection for treatment of urinary stress incontinence]

Minimally invasive treatment of urinary incontinence has become a subject of major interest in recent years. We examined the use of transurethral collagen injection for incontinence treatment. A total of 48 patients were selected for this procedure from April 1993 to February 1997-26 male patients (19 post-RPX incontinence and 7 post-TUR incontinence) and 22 female patients (all after previous incontinence surgery) were treated by injection of collagen into the continence region. The whole group underwent an average of 1.8 sessions, and a mean collagen injection volume of 14.5 ml was delivered per session. Mean follow-up was 9.2 months. Of the female population, 68.2% were cured or greatly improved. In the male population only 47.3% of the post-RPX patients and 6/7 of the post-TUR patients benefited from the procedure. In males, treatment outcome depends on the degree of pretreatment incontinence, because all grade III incontinence patients did worse. Therefore we conclude: transurethral collagen injection is an interesting method in the treatment of urinary incontinence if proper patient selection is assured.

[Is retrograde ureteropyelography necessary before kidney pelvis-plasty in childhood?]

For routine evaluation of ureteropelvic junction obstruction in children, sonography, voiding cystogram, IV pyelogram and a renal scan in combination with administration of furosemide are available. Furthermore, often preoperative antegrade or retrograde ureteropyelography is performed. However, the significance of retrograde ureteropyelography in the world literature remains controversial. Therefore, we reviewed the records of 41 children who underwent a pyeloplasty in our department. In 9 children the ureter was visualized by IV pyelogram, voiding cystogram or antegrade ureteropyelography; a retrograde examination of the ureter was performed in 21 children before pyeloplasty in the OR. In 11 children the ureter was not visualized preoperatively. Retrograde ureterography neither gave additional information in any patient nor did it change the operative technique. In the children where the ureter was not visualized preoperatively, no ureteric abnormality was found in association with ureteropelvic junction obstruction. Hence, we conclude that retrograde ureteropyelography before pyeloplasty in children is not necessary, provided that sonography does not show ureteral dilatation.

Laser therapy in dogs and humans--is there a difference?

OBJECTIVE

To compare quantitatively the reduction of volume of benign prostatic hyperplasia (BPH) achieved by laser therapy in dogs and men.

PATIENTS, MATERIALS AND METHODS

Twelve mongrels, with a mean prostatic volume of 33.4 mL, underwent transurethral laser treatment using an Nd:YAG laser with an Ultraline fibre at 60 W power setting. The reduction in prostatic volume was assessed quantitatively 3 months after treatment using stereological methods. Forty patients (mean age 70.2 years, range 51-84) with symptomatic BPH (pre-operative mean prostate volume 46.3 mL) were treated under similar operative conditions with the same laser, power and fibre system. Their urinary performance was assessed before and 6 months after treatment using urinary flow rates, residual volume and a symptom score, and their prostatic volume and necrosis assessed using transrectal ultrasonography.

RESULTS

After laser treatment, the mean reduction in the dog prostate volume was 50% and in the patients was only 21%. The different impact was probably caused by anatomical differences between the human and dog prostate; the human prostate consists mainly of stromal tissue and the canine prostate of glandular epithelium.

CONCLUSIONS

The canine model gives only an approximate guide to the extent of tissue destruction that laser treatment can achieve in men with BPH. Furthermore, tissue differences between men may also affect the response to laser treatment.

[Fatal Yersinia infection after intraoperative transfusion]

A 47-year old man was operated for a malignant tumour of the bladder. During cystectomia packed red cells had to be transfused. Minutes after the rapid transfusion the oxygen saturation dropped. In the following hours his circulation became unstable and the pulmonary function deteriorated. Signs of disseminated intravascular coagulation occurred, making more transfusions necessary. Inspite of all intensive-care efforts the patient died with a multiorgan failure caused by endotoxin shock 66 hours after having received the first transfusions. In the blood cultures of the patient and in the cultures of the first transfused unit of packed red cells Yersinia enterocolitica was isolated.

High-dose pelvic irradiation followed by ileal neobladder urinary diversion: complications and long-term results

OBJECTIVE

To determine the risk of post-operative complications in patients receiving high-dose pelvic irradiation before radical cystectomy and urinary diversion.

PATIENTS AND METHODS

Of 300 patients who underwent orthotopic bladder replacement at our institution from 1986 to 1994, 11 patients (mean age 63 years, range 53-74) did so after receiving high-dose pelvic irradiation. The indication for cystectomy and urinary reconstruction was bladder cancer in seven men, prostate cancer in two men and a contracted bladder due to combined external pelvic irradiation and afterloading radiotherapy in two women.

RESULTS

The post-operative course, including the duration of hospital stay, peri-operative complications and early functional results, did not differ from a control group of non-irradiated patients, and no patients died. The mean follow-up was 22 months (range 10-37) and revealed satisfactory results in seven of 11 patients. A neovesicoperitoneal fistula developed in one woman 10 months after surgery and was repaired by laparotomy. A neovesicovaginal fistula led to supravesical urinary diversion in the second woman.

CONCLUSIONS

High-dose pelvic irradiation should not be a primary contra-indication for orthotopic urinary diversion using segments of small intestine. For patients who undergo combined external and afterloading radiotherapy, the indication for orthotopic bladder replacement should be considered critically.

[Positron emission tomography in diagnosis of renal cell carcinoma]

PET is a new method for staging malignant tumors; the metabolism is examined and not the morphology. In this study the staging of renal cell carcinoma (RCC) by PET was investigated. In 29 patients PET with fluorodeoxyglucose (FDG) was carried out preoperatively; the PET results were compared to the histology of the OR specimen. In 26 patients a RCC was found histologically, which was diagnosed correctly by PET in 20 patients; in 6 patients a false-negative PET result was obtained. An angiomyolipoma, a pericytoma and a pheochromocytoma showed a false-positive PET result. For lymph-node staging positive nodes were found in 3 patients which was correct; no false-negative result was obtained. In 25 patients the PET result was true-positive; once a false-positive finding occurred. In conclusion, PET offers the advantage that no allergy to FDG is known and a pacemaker or metal implants are not contraindications; in diagnosing RCC, according to our results there is no further advantage of FDG-PET in comparison to standard methods; for lymph-node staging the results are equivalent

[Minimally invasive treatment of stress urinary incontinence by collagen administration. Comparison between endosonography controlled and transurethral submucous collagen injection]

For many years, injectable substances have been in use for the treatment of incontinence. We examined different methods of injecting glutaraldehyde cross-linked bovine collagen injection for their effectiveness in treatment of genuine stress incontinence. In the first group of patients collagen injection was done under endo-ultrasound guidance. In the second group an endoscopic system was used. There was no major difference in patient selection for the two groups. Incontinence symptoms became less severe in only 5 of 15 (33%) patients in the endo-ultrasound group, who then had moderate stress incontinence. Endoscopic collagen treatment resulted in social continence in 15 of the 22 (68.2%) patients. We conclude that endoscopic collagen is superior to endo-ultrasound-guided collagen injection in the treatment of incontinence.

[Is radical prostatectomy a suitable model for determination of PSA half-life?]

A review of the literature relating to PSA half-life reveals great variability in absolute values and pharmacokinetic models. A critical view is needed, however, since some authors suggest that the PSA half-life has implications for diagnosis and prognosis after radical prostatectomy. The aim of our study, therefore, was to characterize the value of PSA half-life determination after radical prostatectomy. Serial serum PSA detections were performed in 16 patients with localized prostatic cancer who had undergone radical prostatectomy. Serum PSA was detected on days 0, 1, 2, 3, 6, 9, 12, 15, 18, after radical prostatectomy. In all patients elimination of PSA from serum followed a biphasic logarithmic decay pattern indicating a two-compartment model of first order elimination kinetics (t1 = 1.01 +/- 0.06 days, t2 = 3.42 +/- 0.23 days; P < 0.00001). In this two-compartment model 56.3 +/- 4.8% of the preoperative PSA serum concentration was cleared by the first compartment. To find a biological correlative for the first compartment a mathematical model was developed to approximate the effect of operative blood and plasma loss on PSA serum concentration. In this model changes of hematocrit were used to estimate blood and plasma loss. These calculations showed that 50.12 +/- 3.04% of the preoperative PSA serum concentration was excreted by operative blood loss. This value was not significantly different from the clearance rate calculated for the first compartment. It is, therefore, concluded that the determination of PSA half-life after radical prostatectomy without correction of the operation-related PSA loss is only of limited value.

[Extracorporeal shockwave lithotripsy in children. Complications and long-term results]

ESWL of urinary stones is a well-established treatment in adult patients. The treatment of urinary stones in children has gained increasing importance in recent years. From 1987 to 1993, a series of 27 children with urolithiasis in all parts of the urinary tract were treated by ESWL. Treatment was performed with general anaesthesia or analgosedation. During the treatment no complications occurred. On average, 34 sessions of ESWL, with 2165 shockwaves and 22.3 kV energy, were performed. Minor early complications, such as fever, pain and hydronephrosis, were observed in 7 patients. The overall stone clearance rate was 92%. Stone recurrence occurred in only 1 patient. There were no late complications, such as malfunction of the kidney, skeletal deformation or hypertension after 38 months of follow up. In conclusion, ESWL is the treatment of first choice in paediatric urolithiasis.

[Transurethral laser ablation of the prostate (TULAP). Initial results with 188 patients]

Laser therapy for benign prostatic hyperplasia (BPH) is now the most impressive alternative to transurethral resection of the prostate (TUR-P). Transurethral laser ablation of the prostate (TULAP) is a new technique that combines non-contact and contact laser treatment of BPH. From November 1992 to August 1994, 188 patients were treated by the TULAP technique. Their median age was 70.3 (58-87) years. The mean prostatic volume determined by transrectal ultrasound, was 49.2 ml. A 6-month follow up was possible for 102 patients. The AUA 7-Symptom Score decreased from 29 points preoperatively to 6 points after 6 months. Residual urine volume decreased from 205 ml to 27 ml after 6 months. Maximum flow rate increased from 7.2 ml/s to 19.3 ml/s after 6 months. No severe complications were observed, and in particular no major bleeding or TUR syndrome. We regard the TULAP procedure as an effective treatment alternative for obstructive symptoms caused by BPH.

[Initial experiences with the Memotherm Stent in treatment of benign prostatic hyperplasia]

We report our experience with a new thermosensitive stent (Memotherm), which has been invented recently as an alternative method for treatment of benign prostatic hyperplasia. The wall of this stent is a thermoreactive mesh made of nitinol, which reaches its maximum force of expansion at body temperature. Its high degree of flexibility allows the Memotherm stent to fit the natural course of the prostatic urethra. This stent is available in different sizes between 2 and 8 cm to meet the demand for different lengths of prostatic urethra. Furthermore, the meshed structure of this stent allows its atraumatic removal. From April 1992 to September 1993, 54 consecutive patients with benign prostatic hyperplasia and Memotherm stents inserted. The mean patient age was 76.1 years (range 61-98 years). Patients were considered suitable for treatment with the Memotherm stent when they presented with a poor operative risk. Mean prostatic volume was 51.9 +/- 25 ml (20-150 ml), and on average a stent measured 32.3 +/- 9.5 mm (20-70 mm). Preoperatively, only 14 patients (26%) were able to void, and 40 patients (74%) had had a transurethral or suprapubic catheter placed. After placement of the Memotherm stent, 53 of 54 patients were able to void. In the patients who were able to void preoperatively, the mean maximum flow rate increased from 4.5 ml/s to 15.8 ml/s within the first 6 months after treatment. Within the same period of time, the mean residual urine volume decreased from 194.4 ml to 11.8 ml, and the AUA 6-Symptom Score improved from 24 to 3.5 points. All differences are statistically significant (P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Minimal invasive therapy of prostatic abscess by transrectal ultrasound-guided perineal drainage

Prostatic abscess is a rare but severe disease. Conventional therapy is transurethral resection of the prostatic abscess. Since the advent of transrectal ultrasound (TRUS) a minimal-invasive treatment of prostatic abscess by TRUS-guided perineal drainage under local anesthesia is available. We report on our experience in 6 patients with prostatic abscess. TRUS is a simple, rapid, easily accessible, and accurate method for diagnosis, therapy and follow-up of a prostatic abscess. TRUS-guided perineal drainage of a prostatic abscess is an effective, minimal-invasive and cost-effective treatment without adverse side effects.

Thermosensitive stent (Memotherm) for the treatment of benign prostatic hyperplasia

Recently, more and more alternative therapeutic methods have been used for the treatment of benign prostatic hyperplasia (BPH). We will report on therapeutic results with a new thermosensitive stent system (Memotherm). This wire mesh stent has been designed especially for urological purposes. It is made of Nitinol, a thermoreactive material, and gains its maximum expansion force al body temperature. Due to the properties of the material the stent is flexible and can adapt to the anatomical conditions of the prostatic part of the urethra. Because of individual variations in the length of the prostatic part of the urethra, the system is available in lengths from 2 to 8 cm. The knitted structure for the first time allows atraumatic removal. Between April, 1992, and September, 1993, we treated a total of 54 BPH patients with the stent system. Mean patient age was 76.1 +/- 7.6 years (61-98). Mean prostatic volume was 51.9 +/- 25 ml (20-150), and the length of the applicated stents was 32.3 +/- 9.5 mm (20-70). Patient selection for stent treatment was carried out with regard to the preoperative risk status of this patient group. Fourteen (26%) of the patients treated were able to micturate before operation; in 40 (74%) urinary drainage was accomplished by means of an indwelling catheter. Following stent application, 53 out of 54 patients were able to micturate. With the first group (preoperative voiding ability), maximum flow had increased from 4.5 ml/s to a mean of 15.8 ml/s, while residual urine volume had decreased from 194.4 ml to 11.8 ml and the AUA 6 Symptoms Score had improved from 24 points to 3.5 points 6 months after stent application. All differences were statistically significant (P < 0.02). With the second group (no preoperative voiding ability), the AUA 6 Symptoms Score had improved from 25 points to 3.9 points (P < 0.02) 6 months after the operation, at which time the mean maximum flow rate was 14.8 ml/s and residual urine volume 14.8 ml. There was no statistically significant difference between the patients who were able and those who were unable to micturate before operation. One case of epididymitis was the only major complication observed after stent placement. Frequent urgency symptoms (30 out of 54 patients; 55.5%) subsided after a mean period of 1 week. The Memotherm stent offers an interesting therapeutic alternative for BPH risk patients.

[Ultrastructural studies of the ileum neobladder]

Four patients had cold biopsies of the ileal mucosa 15-40 months after bladder substitution with an ileal neobladder. We used electron optical systems encompassing scanning electron microscopy and transmission electron microscopy for ultrastructural evaluation of the specimen. The changes observed did not vary markedly from patient to patient. In all biopsies the number of normal intestinal mucosa cells as well as mitochondrial density and number of microvilli was significantly reduced. In contrast the density of goblet cells was similar to that found in normal ileal tissue. These findings confirm the clinical observation that, on long-term follow-up, patients with an ileal neobladder show a decrease in urinary resorption via the ileal mucosa, whereas mucus secretion tends to be constant.

[PSA volume quotient: an additional parameter in diagnosis of locally confined prostate cancer]

The sensitivity and specificity of prostate-specific antigen density (PSAD), a quotient of serum PSA and prostate volume, in the detection of localized prostate cancer was analysed in a prospective study. A total of 235 patients were examined, 145 without prostate cancer and 90 patients before radical prostatectomy for localized prostate cancer. PSAD was determined by dividing the serum level of PSA by the volume of the entire prostate (estimated by transrectal ultrasound) and multiplying by 100. Using a PSAD of 15, the specificity achieved in our collective was the same as with an absolute PSA value of 4 ng/ml (88.9-90%). On the other hand, with the PSAD of 15 we also found the same sensitivity as with an ab-solute PSA of 10 ng/ml (75.2-76.5%).

[Differential diagnostic problems in a polycystic, atypically calcified renal cell carcinoma]

The renal cell carcinoma as the most common malignant renal tumour in adults may produce diagnostic difficulties if it follows atypical patterns. In the case of a polycystic renal tumour this problem is discussed; the high sensitivity of CT and MRT in detecting even small areas of solid tumour is shown.

[Imaging procedures in preoperative lymph node staging of invasive bladder cancer. Necessary or superfluous?]

A staging programme for detection of lymph node involvement before radical cystectomy has been carried out in 22 patients. The programme includes: intravenous pyelography, chest X-ray, abdominal sonography, bone scan, CT and MRI. Also an immunoscintigraphic examination using monoclonal anti-CEA antibody (TUMAK BW 421/26) was done in every patient. Preoperative lymph node staging using CT, MRI and immunoscintigraphy was compared with post-operative histological staging: a total of 5 patients were found to have lymph node involvement. In none of them had lymph node involvement been predicted on the basis of CT, MRI or immunoscintigraphy.

[Kidney carcinoma in Bourneville-Pringle disease]

We report a case of renal cell carcinoma in a 28-year-old woman with Bourneville-Pringle's disease. A review of the literature revealed 16 cases of renal cell carcinoma associated with tuberous sclerosis. The incidence of angiomyolipoma among patients with Bourneville-Pringle's disease is cited in the literature as 40-80%, but this is based solely on two early publications, while other publications suggest a considerably higher incidence of renal cell carcinoma in Bourneville-Pringle's disease, as in other phacomatoses (Hippel-Lindau's disease). We therefore recommend screening for renal cell carcinoma in patients with Bourneville-Pringle's disease.

[Intra- and postoperative morbidity of radical prostatectomy]

Operation-related morbidity was analyzed in 147 patients, who had undergone radical prostatectomy during the last 3 years. Six major complications (4.1%) had occurred requiring surgical revision. One single postoperative death (0.7%) was caused by a pulmonary embolus. In 51 patients (34.7%) minor complications were noted. Urinary incontinence was severe in 4 patients (3.9%), which was treated by an artificial sphincter in one man during the follow-up period. Twelve patients (11.8%) complained of stress incontinence, grade I-II. Postoperative determinations of serum PSA were below the detectable range in 81% of the patients, including those with a locally advanced tumor stage and adjuvant antiandrogen therapy. Based on our data, it is concluded that radical prostatectomy is today a safe and standardized operative procedure.