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Background Case volume has been suggested to affect surgical outcomes in different arrays of procedures. We aimed to delineate the relationship between case volume and surgical outcomes and quality of care criteria of radical cystectomy (RC) in a prospectively collected multicenter cohort. Patients and Methods This was a retrospective analysis of a prospectively collected European cohort of patients with bladder cancer treated with RC in 2011. We relied on 479 and 459 eligible patients with available information on hospital case volume and surgeon case volume, respectively. Hospital case volume was divided into tertiles, and surgeon volume was dichotomized according to the median annual number of surgeries performed. Binomial generalized estimating equations controlling for potential known confounders and inter-hospital clustering assessed the independent association of case volume with short-term complications and mortality, as well as the fulfillment of quality of care criteria. Results The high-volume threshold for hospitals was 45 RCs and, for high-volume surgeons, was > 15 cases annually. In adjusted analyses, high hospital volume remained an independent predictor of fewer 30-day (odds ratio, 0.34; P = .002) and 60- to 90-day (odds ratio, 0.41; P = .03) major complications but not of fulfilling quality of care criteria or mortality. No difference between surgeon volume groups was noted for complications, quality of care criteria, or mortality after adjustments. Conclusion The coordination of care at high-volume hospitals might confer a similar important factor in postoperative outcomes as surgeon case volume in RC. This points to organizational elements in high-volume hospitals that enable them to react more appropriately to adverse events after surgery.

Background Nodal metastasis is the strongest risk factor of disease recurrence in patients with localized prostate cancer (PCa) treated with radical prostatectomy (RP). Objective To develop a model that allows quantification of the likelihood that a pathologically node-negative patient is indeed free of nodal metastasis. Design, setting, and participants Data from patients treated with RP and pelvic lymph node dissection (PLND; n = 7135) for PCa between 2000 and 2011 were analyzed. For external validation, we used data from patients (n = 4209) who underwent an anatomically defined extended PLND. Intervention RP and PLND. Outcome measurements and statistical analysis We developed a novel pathologic (postoperative) nodal staging score (pNSS) that represents the probability that a patient is correctly staged as node negative based on the number of examined nodes and the patient's characteristics. Results and limitations In the development and validation cohorts, the probability of missing a positive node decreases with an increasing number of nodes examined. Whereas in pT2 patients, a 90% pNSS was achieved with one single examined node in both the development and validation cohort, a similar level of nodal staging accuracy was achieved in pT3a patients by examining five and nine nodes, respectively. The pT3b/T4 patients achieved a pNSS of 80% and 70% when 17 and 20 nodes in the development and validation cohort were examined, respectively. This study is limited by its retrospective design and multicenter nature. The number of nodes removed was not directly correlated with the extent/template of PLND. Conclusions Every patient needs PLND for accurate nodal staging. However, a one-size-fits-all approach is too inaccurate. We developed a tool that indicates a node-negative patient is indeed free of lymph node metastasis by evaluating the number of examined nodes, pT stage, RP Gleason score, surgical margins, and prostate-specific antigen. This tool may help in postoperative decision making. © 2013 European Association of Urology.

Das Ziel der aktuellen Studie war die Evaluierung perioperativer Komplikationen unter Verwendung der Clavien-Dindo Komplikationsklassifikation zum Vergleich zwischen retropubischer, endoskopischer und roboter-assistierter radikaler Protatektomie mithilfe einer prospektiv erhobenen Datenbank.

Objective To assess the prognostic role of extranodal extension (ENE) and the size of the largest lymph node (LN) metastasis in predicting early biochemical relapse (eBCR) in patients with LN metastasis after radical prostatectomy (RP). Patients and Methods We evaluated BCR-free survival in men with LN metastases after RP and pelvic LN dissection performed in six high-volume centres. Multivariable Cox regression tested the role of ENE and diameter of largest LN metastasis in predicting eBCR after adjusting for clinicopathological variables. We compared the discrimination of multivariable models including ENE, the size of largest LN metastasis and the number of positive LNs. Results Overall, 484 patients were included. The median (interquartile range, IQR) follow-up was 16.1 (6–27.5) months. The median (IQR) number of removed LNs was 10 (4–14), and the median (IQR) number of positive LNs was 1 (1–2). ENE was present in 280 (58%) patients, and 211 (44%) had their largest metastasis >10 mm. Patients with ENE and/or largest metastasis of >10 mm had significantly worse eBCR-free survival (all P < 0.01). On multivariable analysis, number of positive LNs (≤2 vs >2) and the diameter of LN metastasis (≤10 vs >10 mm), but not ENE, were significant predictors of eBCR (all P < 0.003). ENE and diameter of LN metastasis increased the area under the curve of a baseline multivariable model (0.663) by 0.016 points. Conclusions The diameter of the largest LN metastasis and the number of positive LNs are independent predictors of eBCR. Considered together, ENE and the diameter of the largest LN metastasis have less discrimination than the number of positive LNs.

The impact of diabetes mellitus (DM) and metformin use on biochemical recurrence (BCR) in patients treated with radical prostatectomy (RP) remains controversial. We retrospectively evaluated 6,863 patients who underwent RP for clinically localized PC between 2000 and 2011. Univariable and multivariable Cox regression models addressed the association of DM and metformin use with BCR. Overall, 664 patients had a diagnosis of DM from which 287 (43 %) were on metformin and 377 (57 %) were on anti-diabetics other than metformin. DM and metformin were not associated with any clinicopathologic features (p values >0.05). Within a median follow-up of 25 months (interquartile range 35 months), 774 (11.3 %) patients experienced BCR. Actuarial 5-year biochemical-free survival was 83 % for non-diabetic, 79 % for diabetic patients without metformin use, and 85 % for diabetic patients with metformin use (log rank p = 0.17). In uni- and multivariable Cox regression analyses with the non-diabetic group as referent, DM without metformin use (HR = 0.99; 95 % CI 0.75–1.30, p = 0.65) and DM with metformin use (HR = 0.84, 95 % CI 0.58–1.22, p = 0.36) were not associated with BCR after RP. A subgroup analysis stratified by nodal status, surgical margins, tumor stage, and Gleason sum did not reveal any significant association between DM, use of metformin and risk of BCR. We found no association between DM or metformin use and cancer-specific features or BCR in patients treated with RP. The effect of DM and metformin on complications, wound healing and overall survival needs to be assessed in similar cohorts.

Background: Neoadjuvant chemotherapy with methotrexate-vinblastine-doxorubicin-cisplatin (MVAC) is the standard of care for muscle-invasive urothelial bladder cancer. Gemcitabine plus cisplatin (GC) shows similar efficacy with less toxicity in the metastatic setting and has therefore often been used interchangeably with MVAC. We report on the efficacy and safety of neoadjuvant GC in patients with locally advanced urothelial cancer. Materials and Methods: We prospectively evaluated 87 patients in 2 centers. Their median age was 68 years. Treatment consisted of 3× GC prior to radical cystectomy. The primary endpoint was pathologic response. The secondary endpoints were safety, progression-free survival (PFS), and overall survival (OS). Results: In all, 83 patients finished chemotherapy; 80 patients were evaluable for the primary endpoint. Pathologic complete response (pCR) was achieved in 22.5% and near pCR was seen in 33.7% of the patients. The 1-year PFS rate was 79.5% among those patients achieving ≤pT2 versus 100% among those patients achieving pCR or near pCR (p = 0.041). Five-year OS was 61.8% (95% CI 67.6 to NA). GC was well tolerated. Grade 3/4 toxicities occurred in 38% of the patients. There was no grade 3/4 renal toxicity, febrile neutropenia, or death. Conclusion: Neoadjuvant GC is a well-tolerated regimen. Although the pathologic response is lower than that reported with MVAC, our data support GC as a feasible option in the absence of a prospective randomized comparison, particularly for older patients, since its toxicity is lower than that of MVAC.

Background: Positive surgical margins (PSMs) are a known risk factor for biochemical recurrence in patients with prostate cancer (PCa) and are potentially affected by surgical technique and volume. Objective: To investigate whether radical prostatectomy (RP) modality and volume affect PSM rates. Design, setting, and participants: Fourteen institutions in Europe, the United States, and Australia were invited to participate in this study, all of which retrospectively provided margins data on 9778 open RP, 4918 laparoscopic RP, and 7697 robotic RP patients operated on between January 2000 and October 2011. Outcome measurements and statistical analyses: The outcome measure was PSM rate. Multivariable logistic regression analyses and propensity score methods identified odds ratios for risk of a PSM for one modality compared with another, after adjustment for age, preoperative prostate-specific antigen, postoperative Gleason score, pathologic stage, and year of surgery. Classic adjustment using standard covariates was also implemented to compare PSM rates based on center volume for each minimally invasive surgical cohort. Results and limitations: Open RP patients had higher-risk PCa at time of surgery on average and were operated on earlier in the study time period on average, compared with minimally invasive cohorts. Crude margin rates were lowest for robotic RP (13.8%), intermediate for laparoscopic RP (16.3%), and highest for open RP (22.8%); significant differences persisted, although were ameliorated, after statistical adjustments. Lower-volume centers had increased risks of PSM compared with the highest-volume center for both laparoscopic RP and robotic RP. The study is limited by its nonrandomized nature; missing data across covariates, especially year of surgery in many of the open cohort cases; lack of standardized histologic processing and central pathology review; and lack of information regarding potential confounders such as patient comorbidity, nerve-sparing status, lymph node status, tumor volume, and individual surgeon caseload. Conclusions: This multinational, multi-institutional study of 22 393 patients after RP suggests that PSM rates might be lower after minimally invasive techniques than after open RP and that PSM rates are affected by center volume in laparoscopic and robotic cases. Patient summary: In this study, we compared the effectiveness of different types of surgery for prostate cancer by looking at the rates of cancer cells left at the margins of what was removed in the operations. We compared open, keyhole, and robotic surgery from many centers across the globe and found that robotic and keyhole operations appeared to have lower margin rates than open surgeries. How many cases a center and surgeon do seems to affect this rate for both robotic and keyhole procedures. (C) 2013 European Association of Urology. Published by Elsevier B. V. All rights reserved.

Introduction Guidelines recommend neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) in patients with urothelial carcinoma of the bladder in clinical stages T2-T4a, cN0M0. We examined the frequency and current practice of NAC and sought to identify predictors for the use of NAC in a prospective contemporary cohort. Materials and Methods We analyzed prospective data from 679 patients in the PROMETRICS (PROspective MulticEnTer RadIcal Cystectomy Series 2011) database. All patients underwent RC in 2011. Uni- and multivariable regression analyses identified predictors of NAC application. Furthermore, a questionnaire was used to evaluate the practice patterns of NAC at the PROMETRICS centers. Results A total of 235 patients (35%) were included in the analysis. Only 15 patients (2.2%) received NAC before RC. Younger age ( P = .035), lower case volume of the center ( P P = .038) were identified as predictors for NAC. Of the 200 urologists who replied to the questionnaire, 69% (n = 125) declared tumor stage cT3-4 a/o N1M0 to be the best indication for NAC application, although 45% of the urologists stated that they would not perform NAC despite recommendations. The decision for NAC was made by the individual urologist in 69% of cases, and only 29% reported that all cases were discussed in an interdisciplinary tumor board. Conclusion NAC was rarely applied in the present cohort. We observed a discrepancy between guideline recommendations and practice patterns, despite medical indication and pre-therapeutic interdisciplinary discussion. The potential benefit of NAC within a multimodal approach seems to be neglected by many urologists.

Purpose: We report on our initial experience in terms of efficacy and safety with a new, self-anchoring adjustable transobturator male system (A.M.I.® ATOMS System) for the treatment of male stress urinary incontinence after prostate surgery.Materials and Methods: In this prospective, nonrandomized single center study conducted between March and December 2009, patients with stress urinary incontinence secondary to prostatic surgery were treated with the ATOMS device. Urethroscopy, filling and voiding cystometry were performed preoperatively for all patients. In addition, incontinence symptoms were assessed, and a physical examination, 24-hour pad test and 24-hour pad count were performed before and after surgery.Results: A total of 38 patients were included in the study (36 after radical prostatectomy, 2 after benign prostatic hyperplasia surgery). No intraoperative complications occurred. Mean number of adjustments during followup was 3.97 (range 0 to 9). At a mean followup of 16.9 months (range 13 to 21...

Rezente multizenter-Studien haben viel zum Verstandnis klinisch-pathologischer Kriterien und deren Implikationen fur die Prognose des Urothelkarzinoms des oberen Harntraktes nach radikaler Nephroureterektomie beigetragen und gezeigt, dass es eine Vielzahl von Prognoseparametern gibt, die den Verlauf dieser verhaltnismasig seltenen Erkrankung beeinflussen. So wurden der Einfluss des Geschlechtes und des Alters sowie das Vorliegen von lokalen Beschwerden oder einer Nierenstauung neben pathologischer Kriterien wie dem Staging, Tumor-Architektur, Lymphknoteninvasion, Lokalisation und dem Vorliegen eines CIS oder Tumornekrosen auf die Prognose und Rezidivneigung nach radikaler Nephroureterektomie untersucht. Weitere multizentrische, idealerweise prospektive Studien sind notig, um die bisher aus retrospektiven Studien gewonnenen Erkenntnisse zu validieren.

PSA ist mit Sicherheit der meistgenutzte und meistdiskutierte Marker in der Urologie. Der Einsatz von PSA ist in der in der Hoffnung bedingt, Mortalitat und Morbiditat des Prostatakarzinoms zu senken, welches die haufigste maligne nichtkutane Erkrankung des alteren Mannes in westlichen Industrienationen darstellt. Obwohl es aufgrund des oftmals sehr langen naturlichen Verlaufes bei Prostatakarzinomen sehr schwierig ist, den Nutzen von PSA oder grundsatzlich jeglicher medizinischer Masnahme nachzuweisen, ist aus der Sicht der Autoren die Haufigkeit der PSA-Bestimmungen sehr wohl bedingt durch die vielfaltigen Fragestellungen, wo uns PSA weiterhelfen kann. In Zukunft wird PSA, so nicht ein neuer, potenterer Marker entwickelt und eingefuhrt wird weiter eine grose Rolle spielen. Es wird jedoch auf vielfaltige Kenntnisse des behandelnden Arztes ankommen, um karzinomrelevante Informationen jenseits eines einzelnen PSA-Wertes abzuleiten. Der Einsatz von PSA wird eventuell fruher beginnen und fruher enden (ab 40–75a) und nicht jeder entdeckte Tumor wird tatsachlich auch aktiv therapiert werden.

Das kortikale Nierenzellkarzinom tragt 80–85 % zu den bekannten Neoplasien der Niere bei. Die Symptomatik des Patienten ist entweder auf den Tumor selbst (z. B. Schmerz), Invasion des Harntraktes (z. B. Hamaturie), paraneoplastische Syndromen oder Metastasen zuruckzufuhren. Am haufigsten wird das Nierenzellkarzinom heute als Zufallsbefund eines bildgebenden Verfahrens im Initialstadium detektiert. Die chirurgische Therapie gilt als bevorzugte Behandlung im metastasenfreien Stadium I, II und III. Das 5-Jahresuberleben korreliert eng mit der anatomischen Ausdehnung des Tumors. Systemische Substanzen, wie Targeted- oder Immuntherapie kommen in fortgeschrittenen Stadien zum Einsatz.

The importance of the carcinoma of the prostate is still increasing. It is important to have options such as multimodal therapy. In this article two selected case reports are presented. Treatment options such as surgery, hormonal and irradiation therapy as well as chemotherapy will be discussed. Each patient suffering from carcinoma of prostate should receive individual best therapy.

In previous phase I to III studies docetaxel and vinorelbine have shown promising activity in androgen independent prostate cancer. In the present trial we assessed the efficacy and tolerability of single agent low dose docetaxel vs vinorelbine in patients with advanced androgen independent prostate cancer.A total of 40 chemotherapy naive patients with histologically proven androgen independent prostate cancer, adequate androgen ablation, and clinical and/or biochemical progression were randomly assigned to receive either 25 mg/m(2) docetaxel (arm A) or 25 mg/m(2) vinorelbine (arm B) weekly. Treatment was continued until clinical and/or biochemical progression. In cases of progression patients switched to the alternative treatment arm. The primary end point was time to disease progression. Secondary end points included prostate specific antigen response rates in sequential treatment, analgesic response and toxicity.The current analysis showed a doubled risk of progression in treatment arm B. The median time to first disease progression was 14.5 months for arm A vs 4.4 months for arm B. The proportion of patients with a greater than 50% prostate specific antigen decrease on first line therapy was significantly higher in arm A (62.5%) compared to arm B (11.1%) (p = 0.0033). After progression to docetaxel second line vinorelbine yielded a greater than 50% prostate specific antigen response rate of 28.6% vs 62.5% for second line docetaxel. Clinically significant toxicity occurred more often in arm B with neutropenia grade 4 seen in 22% and grade 3 in 28% of patients (p = 0.0005) during the first treatment phase.While weekly application of both cytotoxic agents was well tolerated, this study demonstrates the superiority of docetaxel vs vinorelbine as monotherapy in the treatment of androgen independent prostate cancer.

Muscle invasive bladder cancer is still an interdisciplinary problem for urologists, oncologists and radiotherapists. Our efforts should be on finding the right time for the right intervention such as radical cystectomy or chemotherapy and/or irradiation. New forms of diagnostics and therapies are now available, or at least in clinical trails, to make therapy more effective.

The importance of the carcinoma of the prostate is still increasing. It is important to know about the possibilities of diagnosis and treatment options. In this article risk factors, diagnosis and treatment options such as surgery, hormonal and irradiation therapy as well as "wait and see" strategy will be discussed. Each patient suffering from carcinoma of prostate should receive the therapy best suited to his needs.

Wahrend im neoadjuvanten Setting bei vielen Tumoren haufig eine Chemotherapie verwendet wird, kann beim Prostatakarzinom aufgrund der Hormonsensibilitat neoadjuvant eine Hormonmanipulation angewendet werden. Die neoadjuvante Hormontherapie beim Prostatakarzinom vor einer radikalen Prostatektomie ist in der Literatur nur schlecht und uneinheitlich beschrieben. Die Daten beschreiben uneinheitlich die Dauer der neoadjuvanten Therapie und geben unzureichend Verbesserungen im Gesamtuberleben an. Daher liegt der Schluss nahe, dass man diese Therapieoption noch genauer und konsequenter untersuchen sollte. Die Indikationsstellung sollte gut dokumentiert sein und die Hormonblockade sollte unserer Meinung zumindest fur 9 Monate erfolgen.

Background:Pelvic lymph node dissection in patients undergoing radical prostatectomy for clinically localised prostate cancer is not without morbidity and its therapeutical benefit is still a matter of debate. The objective of this study was to develop a model that allows preoperative determination of the minimum number of lymph nodes needed to be removed at radical prostatectomy to ensure true nodal status.Methods:We analysed data from 4770 patients treated with radical prostatectomy and pelvic lymph node dissection between 2000 and 2011 from eight academic centres. For external validation of our model, we used data from a cohort of 3595 patients who underwent an anatomically defined extended pelvic lymph node dissection. We estimated the sensitivity of pathological nodal staging using a beta-binomial model and developed a novel clinical (preoperative) nodal staging score (cNSS), which represents the probability that a patient has lymph node metastasis as a function of the number of examined nodes.Results:In the development and validation cohorts, the probability of missing a positive lymph node decreases with increase in the number of nodes examined. A 90% cNSS can be achieved in the development and validation cohorts by examining 1-6 nodes in cT1 and 6-8 nodes in cT2 tumours. With 11 nodes examined, patients in the development and validation cohorts achieved a cNSS of 90% and 80% with cT3 tumours, respectively.Conclusions:Pelvic lymph node dissection is the only reliable technique to ensure accurate nodal staging in patients treated with radical prostatectomy for clinically localised prostate cancer. The minimum number of examined lymph nodes needed for accurate nodal staging may be predictable, being strongly dependent on prostate cancer characteristics at diagnosis. © 2014 Cancer Research UK.

Objectives: To determine if the number of lymph nodes (LNs) removed is an independent predictor of biochemical recurrence (BCR) in patients without LN metastases undergoing radical prostatectomy (RP). Material and methods: Retrospective analysis of 7,310 patients treated at 7 centers with RP and pelvic LN dissection for clinically localized prostate cancer between 2000 and 2011. Patients with LN metastases (n = 398) and other reasons (stated later in the article) (n = 372) were excluded, which left 6,540 patients for the final analyses. Results: Overall, median biopsy and RP Gleason score were both 7; median prostate specific antigen level was 6. ng/ml (interquartile range [IQR]: 5); and median number of LNs removed was 6 (IQR: 8). A total of 3,698 (57%), 2,064 (32%), and 508 (8%) patients had ≥6, ≥10, and ≥20 LNs removed, respectively. Patients with more LNs removed were older, had a higher prostate specific antigen level, had higher clinical and pathologic T stage, and had higher RP Gleason score (all P

Bei muskelinvasiven Blasentumoren bietet die radikale chirurgische Entfernung der Harnblase die beste Aussicht auf Heilung. Pioniere der experimentellen Laparoskopie haben bereits 1992 die Harnblase laparoskopisch entfernt. Erst im Jahre 2000 gelang es Gill komplett laparoskopisch bei 2 Patienten eine radikale Zystektomie mit Anlage eines Ileum Conduits durchzufuhren. Seither hat die Etablierung der laparoskopischen radikalen Prostatektomie in einigen europaischen und amerikanischen Zentren zu einem ausgepragten Innovationsschub bei OP-Instrumentarium und -technik gefuhrt. Wird die laparoskopische Prostatektomie routinemasig gut beherrscht, ist der Schritt zur laparoskopischen Zystektomie nicht sehr gros.

To assess the prognostic role of extranodal extension (ENE) and the size of the largest lymph node (LN) metastasis in predicting early biochemical relapse (eBCR) in patients with LN metastasis after radical prostatectomy (RP).We evaluated BCR-free survival in men with LN metastases after RP and pelvic LN dissection performed in six high-volume centres. Multivariable Cox regression tested the role of ENE and diameter of largest LN metastasis in predicting eBCR after adjusting for clinicopathological variables. We compared the discrimination of multivariable models including ENE, the size of largest LN metastasis and the number of positive LNs.Overall, 484 patients were included. The median (interquartile range, IQR) follow-up was 16.1 (6-27.5) months. The median (IQR) number of removed LNs was 10 (4-14), and the median (IQR) number of positive LNs was 1 (1-2). ENE was present in 280 (58%) patients, and 211 (44%) had their largest metastasis10 mm. Patients with ENE and/or largest metastasis of10 mm had significantly worse eBCR-free survival (all P0.01). On multivariable analysis, number of positive LNs (≤2 vs2) and the diameter of LN metastasis (≤10 vs10 mm), but not ENE, were significant predictors of eBCR (all P0.003). ENE and diameter of LN metastasis increased the area under the curve of a baseline multivariable model (0.663) by 0.016 points.The diameter of the largest LN metastasis and the number of positive LNs are independent predictors of eBCR. Considered together, ENE and the diameter of the largest LN metastasis have less discrimination than the number of positive LNs.

To test a novel technique of processing prostate biopsy specimen by marking the peripheral end (PE) as a predictive tool for positive resection margin after radical prostatectomy (RP) or for locally advanced carcinoma of the prostate (PC). Prospective, multi-institutional study of a consecutive cohort of men who underwent prostate biopsy with marking the peripheral biopsy end and subsequent RP at the same institution. The study cohort comprised 445 men with a mean age of 63 years (40–77 years). Overall, PE-positive cores were found in 174 men (39.1 %) and R1 status was diagnosed in 132 men after RP (29.7 %). In the multivariate analysis, the presence of at least one PE-positive core was correlated with an increased risk of R1 status (OR 2.29, 95 % CI 1.31–4.00, p = 0.003) and was the strongest predictor followed by Gleason score, PSA and percentage of positive cores. Including all predictive parameters, a nomogram with a concordance index of 72.1 % was calculated. In the pT3/pT4 subgroup, PE positivity was the only predictive factor for R1 status (OR 3.03, 95 % CI 1.36–6.75, p = 0.006). In pT2 stage, no single factor was predictive for R1 status. PE-positive biopsies were not predictive for pT3/pT4 stages. PC at the peripheral end of prostate biopsy specimen predicts an increased risk of R1 status in subsequent RP. This simple and cheap technique may contribute to an increased accuracy of risk stratification for curative treatment for PC.

The objective of the present study was to evaluate perioperative complications between retropubic, endoscopic and robot-assisted radical prostatectomy on basis of a prospective maintained database using the Clavien-Dindo classification of complications. According to our results, implementation of the radical robot-assisted laparoscopic prostatectomy shows a trend to a decrease of minor complications compared to retropubic and endoscopic radical prostatectomy. Major complications are comparable between all three procedures.

To evaluate the reliability of sentinel lymphadenectomy compared to extended lymphadenectomy in men undergoing radical prostatectomy (RP).A consecutive cohort of men with intermediate- to high-risk prostate cancer underwent RP with sentinel LA with intraoperative frozen section. In addition, extended LA was carried out in all cases. The endpoint was lymph node-positivity.In total, 54 men with a mean age of 65.3 (50.9-75.6) years were analyzed. The mean preoperative prostate-specific antigen was 10.6 (2.8-66.5) ng/ml, mean number of disease-positive cores was 5.8 (1-13), digital rectal examination was positive in 29 men (53.7%). In 12 men (22.2%), a positive lymph node was found (pN1). sLA was positive in 11 cases. One patient had a positive lymph node in eLA not found with sLA. The positive predictive value of frozen section was 50%; the respective figure for sLA compared to eLA was 91.6%.In this cohort, revealing a high prevalence of disease-positive lymph nodes, sLA was a reliable technique with a low rate of false negativity.

Despite the broad use of PSA-testing in western medicine, still an estimated 1/3 of carcinomas of the prostate (PC) are diagnosed in a locally advanced or metastatic stage. In the current treatment-algorithm for locally advanced PC, radical prostatectomy, external beam radiation therapy (with and without hormonal therapy) and primary androgen deprivation are available. In fact, in a majority of patients treatment of this tumor stage will be a multimodal approach, which has to be discussed individually. For metastatic PC hormonal deprivation therapy is still the gold standard. Beside LHRH-agonists, surgical castration and complete androgen deprivation today LHRH-antagonists represent the different therapeutic options in this tumor stage. Effects on natural course of this disease have to be balanced to the side effects of long-term therapy. Castration-resistant PC is not the object of this overview even though there are a variety of new medical interventions emerging for the treatment of this stage of PC.

Recent multicentric studies contributed significantly to the understanding of clinical and pathological criteria and their implications as prognosticators of the upper urinary tract urothelial carcinoma. They demonstrated a large variety of prognosticators influencing the course of this rare disease. The influence of gender and age and the presence of symptoms and renal obstruction in addition to pathologic criteria such as staging, tumor architecture, lymphnode invasion, localization and the presence of CIS or tumor necrosis on prognosis and disease recurrence after radical nephroureterectomy were investigated. Additional multicentric, ideally prospective studies are warranted to validate current findings.

As neoadjuvant chemotherapy is established for a variety of nonorgan confined malignancies, neoadjuvant hormone ablation for hormone sensitive prostate cancer has demonstrated encouraging results. Neoadjuvant therapy not only provides possible early systemic treatment for subclinical distant disease, but also aims to improve local disease control and to increase the number of patients eligible for definitive local therapy via downstaging. However, only limited, heterogenous studies are available. Therefore, prospective high quality studies are urgently needed to assess the future role of neoadjuvant hormone ablation.

Prostate-specific antigen (PSA) doubling-time (PSA-DT) is an important indicator of progression and survival in men with prostate cancer. Three major limitations regarding PSA-DT determination may lead to inconsistent results: the variety of mathematical methods currently applied, the non-standardized handling of input variables and the potential lack of accuracy due to PSA variability. The aim of this project was to develop a reproducible PSA-DT determination tool which simultaneously provides a PSA-DT error estimation.An internet-based PSA-DT calculation tool via nonlinear optimization implementing the least squares error method using the most recent three PSA values was developed. PSA-DT calculation error is estimated via randomly disturbed measurement data streams (n=65) based on a variable (5-25%) PSA variability.According to a simulation in five men, PSA-DT was calculated to be between 1.7 and 15 month (mean: 6.3 month) and determined with another standard tool between 1.3 and 14.5 month (mean: 4.2 month).We present a defined, open and reproducible PSA-DT calculation and PSA-DT error estimation tool based on a standardized PSA data input. This tool is not better compared to other methods but is scientifically standardized and freely accessible via the following internet address: http://adam.drahtwarenhandlung.at/webapp/mg2008/chapter_prostata4/example_psa.

We studied 35 patients with vasculogenic impotence who underwent an operation since 1986 and who were followed postoperatively for a minimum of 1.5 years. In all patients a microsurgical anastomosis was performed between the inferior epigastric artery and the arteriovenous shunt of the dorsal penile vessels. Potency was restored or improved in 77% of the patients during the longterm observation. Doppler or duplex sonography confirmed the same percentage of patent anastomoses. Through microsurgical modifications of the Hauri procedure and the interposition of free venous grafts, it was possible to operate further in 3 patients with short epigastric arteries and to treat intraoperative complications effectively in 1.

PSA is without any doubt the most frequently used marker in urology due to its helpful information regarding various aspects of diagnosis, therapy and prognosis in men with prostate cancer. On the other hand, many controversies still exist about the various indications for PSA-determination. The following overview is aimed to analyse the current status of PSA in the management of men undergoing screening, therapy or follow-up of prostate cancer. Anyhow, a detailed knowledge of how to use and interpret PSA and PSA-kinetics is considered to play a crucial role in prostate cancer patients. Current strategies are aimed to start and stop PSA-use earlier.

Renal cell carcinomas, which originate within the renal cortex, constitute 80-85% of primary renal neoplasms. Patients can present with a range of symptoms due to the tumor itself (e.g., mass, pain), invasion of the urinary tract (e.g., hematuria), paraneoplastic syndromes, or the presence of metastases. Renal cell cancer is more frequently being diagnosed incidentally as a consequence of increased use of imaging procedures for other reasons. Surgery is curative in the majority of patients without metastatic disease and is therefore the preferred treatment for patients with stages I, II, and III disease. The five-year survival following the treatment correlates well with the anatomic extent of disease. Systemic therapy with molecularly targeted therapy or immunotherapy is the primary approach for patients with unresectable or recurrent disease.

In muscle-invasive bladder cancer, radical cystectomy is the treatment of choice. Pioneers of laparoscopy have tried to remove the bladder in the early 90s. In the year 2000 Gill et al. managed to remove the bladder and reconstruct the urinary diversion completely laparoscopically for the first time. Since the implementation of the technique of laparoscopic radical prostatectomy in many American and European institutes, the development of technical instruments for laparoscopy is a milestone. With these instruments and with the knowledge of laparoscopic radical prostatectomy, the step to perform a laparoscopic radical cystectomy is not very far.

Muscle invasive bladder cancer is still an interdisciplinary problem for urologists, oncologists and radiotherapists. Our efforts should be on finding the right time for the right intervention such as radical cystectomy or chemotherapy and/or irradiation. New forms of diagnostics and therapies are now available, or at least in clinical trails, to make therapy more effective.

The importance of the carcinoma of the prostate is still increasing. It is important to know about the possibilities of diagnosis and treatment options. In this article risk factors, diagnosis and treatment options such as surgery, hormonal and irradiation therapy as well as "wait and see" strategy will be discussed. Each patient suffering from carcinoma of prostate should receive the therapy best suited to his needs.

Despite the availability of prostaglandin E1 for more than 7 years as a diagnostic and therapeutic tool in patients with erectile dysfunction, the problem of penile discomfort after prostaglandin E1 application has remained unsolved. In a randomized, double-blind, crossover study we investigated the effect of 2 different prostaglandin E1-procaine concentrations on 24 patients suffering from pain following intracorporeal injection of prostaglandin E1 alone. Intracavernous injection of 20 micrograms. prostaglandin E1 with 10 mg. procaine (study 1) failed to improve local painful sensations. The combination of 20 micrograms. prostaglandin E1 with 20 mg. procaine (study 2) decreased the incidence of local pain significantly (p0.01). These preliminary results show that the combination of prostaglandin E1 plus procaine represents a beneficial alternative in patients with penile pain due to the single substance.

We compared the erectile response to intracavernous injection of a combination of papaverine and prostaglandin E1 with that of a combination of papaverine and phentolamine (49 patients), and prostaglandin E1 alone (38). The degree of erection achieved was significantly better with papaverine plus prostaglandin E1 than with papaverine plus phentolamine and the duration of erection was less, although the incidence of prolonged erections (greater than 5 hours) was similar with both combinations. Papaverine with prostaglandin E1 likewise resulted in a significantly better degree of erection than prostaglandin E1 alone (prolonged erections occurred only after the drug combination). All erections subsided spontaneously and none required medical intervention throughout the study. Pain was noted only after injection of prostaglandin E1. The incidence was clearly lower (7 of 38 versus 13 of 38) after the injection of only 5 micrograms. prostaglandin E1 in combination with papaverine (although the difference is not statistically significant). Subjectively, the side effects caused by the drug combination were described as much less dramatic by the patients than after prostaglandin E1 alone. The combination of papaverine and prostaglandin E1 shows a clearly synergistic effect and might suitably replace papaverine plus phentolamine or prostaglandin E1 alone in patients who do not respond well or suffer side effects after high single doses.

A detailed questionnaire was sent to urologists in Austria, Switzerland and West Germany on the frequency of contraceptive vasectomies, vasectomy reversal, technique and success rates. The response rate was 859 of 2,137 (40.2%). The rate of annual contraceptive vasectomies averaged 28,519 or 378 vasectomies per million inhabitants. The rate of vasovasostomies and vasoepididy-mostomies was 8.3 and 3.8 procedures per million inhabitants, respectively. A macroscopic technique was used by 9.5% of the responding urologists, loupes were used by 58.5% and an operating microscope by 32%. The majority (74.1%) preferred a 1-layer technique and an unstented anastomosis (84.4%). The average patency and pregnancy rates were 73 and 47%, respectively, for vasovasostomy and 45 and 18%, respectively, for vasoepididymostomy. A total of 78 alloplastic spermatoceles was reported, with detection of motile spermatozoa in 19 and pregnancy in 1.

4678 Background: In previous phase I-III studies, docetaxel and vinorelbine have shown promising activity in androgen-independent prostate cancer (AIPC). The aim of the present trial was to assess ...

In vitro generation of dysmorphic erythrocytes. In hematuria, dysmorphic red blood cells found in the urine sediment are known to indicate glomerular origin of bleeding. To better understand the mechanisms which might cause the typical membrane changes in dysmorphic erythrocytes in vivo, we have exposed normal human erythrocytes in vitro to an osmotic and enzymatic environment similar to that of the nephron. In addition, treated or untreated erythrocytes were exposed to a hemolytic environment. The morphology of the cells was evaluated by light and electron microscopy in comparison of that of dysmorphic erythrocytes obtained in vivo. Neither the passage of erythrocytes in sequence through various solutions each simulating the tubule fluid in a different part of the nephron, nor exposure to urinary or renal enzymes or to serum per se causes the typical membrane alterations. Upon exposure of passaged erythrocytes to a hemolytic environment, however, 50 to 90% of the cells become dysmorphic in a time and dose dependent fashion. By light and electron microscopy these dysmorphic erythrocytes obtained in vitro are indistinguishable from those obtained in vivo. In contrast, non-passaged red blood cells are not affected by the same hemolytic environment. We conclude that osmotically challenged erythrocytes exposed to a hemolytic environment develop dysmorphic membrane alterations.

The efficiency and side effects of a single dose of intracorporeally applied prostaglandin El (20mcg.) in inducing penile erection were examined. In addition, the effect of this dose of prostaglandin El was compared to the effect of 7.5mg. papaverine plus 0.25mg. phentolamine in a double-blind, crossover designed study. We tested twice 12 men 52.9 ± 7.6 years old (mean ± standard deviation) with erectile dysfunction. On 1 occasion the subjects received 20mcg. prostaglandin El and on the other they received 7.5mg. papaverine and 0.25mg. phentolamine. At this dosage prostaglandin El was most effective in inducing artificial penile erection (11 of 12 patients). However, 75 per cent of the subjects reported burning sensations during the entire period of erection and in 1 prostaglandin El treatment resulted in a sustained erection. At the doses used, prostaglandin El was more effective in inducing penile erection than papaverine plus phentolamine (11 versus 6 patients). Intracavernous injection of pros...