C. Thomas

Bevorzugte Behandlungsoptionen des lokalisierten Prostatakarzinoms von deutschen Urologen und Radioonkologen bei eigener Erkrankung

INTRODUCTION We evaluated the currently preferred primary treatment options among German urologists and radio-oncologists if personally diagnosed with localized prostate cancer, taking into consideration the different prognostic risk groups. MATERIALS AND METHODS A questionnaire was mailed to 3,217 urologists and 598 radio-oncologists. They were asked to choose their preferred primary treatment option if they were personally diagnosed with prostate cancer, taking into consideration the different prognostic risk groups: low risk [Gleason score < or =6, prostate-specific antigen (PSA) < or =10 microg/l, T1c], intermediate risk (Gleason score 7, PSA 11-19 microg/l, T2), and high risk (Gleason score > or =8, PSA> or =20 microg/l, T3). Surgical options were further subdivided according to technique (retropubic, laparoscopic, perineal). RESULTS The questionnaire return rate was 49% for urologists and 41% for radio-oncologists. The mean age was 48 years (28-86) for urologists and 47 years (29-68) for radio-oncologists. Primary surgical treatment was selected by 62% of urologists for low-risk prostate cancer, 90% for intermediate-risk prostate cancer, and 77% for high-risk prostate cancer. Radiotherapy as a primary treatment option was elected by 71% of radio-oncologists for low-risk prostate cancer, 84% for intermediate-risk prostate cancer, and 89% for high-risk prostate cancer. Retropubic, laparoscopic, and perineal prostatectomy would be chosen by 61%, 28%, and 10% of urologists, respectively, for low-risk prostate cancer; by 70%, 24%, and 6%, respectively, for intermediate-risk prostate cancer, and by 80%, 15%, and 5%, respectively for high-risk prostate cancer. CONCLUSION Urologists prefer surgery and radio-oncologists radiotherapy for primary treatment of prostate cancer, irrespective of the prognostic risk group. Particularly for high-risk prostate cancer, the majority of radiooncologists would still choose radiotherapy as a primary treatment option. In the age of minimally invasive surgery, radical retropubic prostatectomy is still the preferred surgical treatment option among urologists for any prognostic risk group.

[Colovesical fistula caused by diverticulitis of the sigmoid colon: diagnosis and treatment].

BACKGROUND Colovesical fistulas caused by diverticulitis of the sigmoid colon are a rare but complex disease for which there is so far no diagnostic and therapeutic algorithm. The goal of this retrospective study including long-term follow-up was to find an algorithm for the diagnosis and therapy of colovesical fistulas caused by diverticular disease. METHODS Between 1982 and 2010 a total of 54 patients (46 male and 8 female) were treated in this institute for a colovesical fistula caused by diverticulitis of the sigmoid colon. The validity of the following diagnostic procedures was considered: poppy seed test, abdominal computed tomography (CT), cystoscopy, coloscopy, cystography and colon enema. The one stage operation included resection of the inflamed colon and a two-lined hand sewn end to end anastomosis of the colon without protective colostomy. After excision of the fistula a two-lined closure of the bladder defect was carried out followed by insertion of a catheter for 7 days. During follow-up patients were examined for recurrence of diverticulitis and colovesical fistula. RESULTS At primary clinical presentation all patients showed clinical symptoms of recurrent urinary tract infections, 74.1% had pneumaturia and 53.7% fecaluria. Fistula detection rates were 94.8% for the poppy seed test, 58.7% for CT scanning, 19.4% for cystography, 38.6% for colon enema, 15.1% for cystoscopy and 9.6% for coloscopy. Of the patients 6 (11.1%) showed perioperative morbidity (3 pneumonia and 3 superficial wound infections) and mortality was 0%. After surgical intervention no recurring diverticulitis or fistulas were detected within a median follow-up period of 62 months (range 1-164 months). CONCLUSIONS The poppy seed test is the most reliable diagnostic method for the detection of colovesical fistulas. The one-stage resection of the fistula of the colon and bladder segment without protective colostomy is safe and feasible.

[Therapy choices of German urologists and radio-oncologists if personally diagnosed with localized prostate cancer].

INTRODUCTION We evaluated the currently preferred primary treatment options among German urologists and radio-oncologists if personally diagnosed with localized prostate cancer, taking into consideration the different prognostic risk groups. MATERIALS AND METHODS A questionnaire was mailed to 3,217 urologists and 598 radio-oncologists. They were asked to choose their preferred primary treatment option if they were personally diagnosed with prostate cancer, taking into consideration the different prognostic risk groups: low risk [Gleason score < or =6, prostate-specific antigen (PSA) < or =10 microg/l, T1c], intermediate risk (Gleason score 7, PSA 11-19 microg/l, T2), and high risk (Gleason score > or =8, PSA> or =20 microg/l, T3). Surgical options were further subdivided according to technique (retropubic, laparoscopic, perineal). RESULTS The questionnaire return rate was 49% for urologists and 41% for radio-oncologists. The mean age was 48 years (28-86) for urologists and 47 years (29-68) for radio-oncologists. Primary surgical treatment was selected by 62% of urologists for low-risk prostate cancer, 90% for intermediate-risk prostate cancer, and 77% for high-risk prostate cancer. Radiotherapy as a primary treatment option was elected by 71% of radio-oncologists for low-risk prostate cancer, 84% for intermediate-risk prostate cancer, and 89% for high-risk prostate cancer. Retropubic, laparoscopic, and perineal prostatectomy would be chosen by 61%, 28%, and 10% of urologists, respectively, for low-risk prostate cancer; by 70%, 24%, and 6%, respectively, for intermediate-risk prostate cancer, and by 80%, 15%, and 5%, respectively for high-risk prostate cancer. CONCLUSION Urologists prefer surgery and radio-oncologists radiotherapy for primary treatment of prostate cancer, irrespective of the prognostic risk group. Particularly for high-risk prostate cancer, the majority of radiooncologists would still choose radiotherapy as a primary treatment option. In the age of minimally invasive surgery, radical retropubic prostatectomy is still the preferred surgical treatment option among urologists for any prognostic risk group.

Kolovesikaler Fisteln auf dem Boden einer Sigmadivertikulitis

BACKGROUND Colovesical fistulas caused by diverticulitis of the sigmoid colon are a rare but complex disease for which there is so far no diagnostic and therapeutic algorithm. The goal of this retrospective study including long-term follow-up was to find an algorithm for the diagnosis and therapy of colovesical fistulas caused by diverticular disease. METHODS Between 1982 and 2010 a total of 54 patients (46 male and 8 female) were treated in this institute for a colovesical fistula caused by diverticulitis of the sigmoid colon. The validity of the following diagnostic procedures was considered: poppy seed test, abdominal computed tomography (CT), cystoscopy, coloscopy, cystography and colon enema. The one stage operation included resection of the inflamed colon and a two-lined hand sewn end to end anastomosis of the colon without protective colostomy. After excision of the fistula a two-lined closure of the bladder defect was carried out followed by insertion of a catheter for 7 days. During follow-up patients were examined for recurrence of diverticulitis and colovesical fistula. RESULTS At primary clinical presentation all patients showed clinical symptoms of recurrent urinary tract infections, 74.1% had pneumaturia and 53.7% fecaluria. Fistula detection rates were 94.8% for the poppy seed test, 58.7% for CT scanning, 19.4% for cystography, 38.6% for colon enema, 15.1% for cystoscopy and 9.6% for coloscopy. Of the patients 6 (11.1%) showed perioperative morbidity (3 pneumonia and 3 superficial wound infections) and mortality was 0%. After surgical intervention no recurring diverticulitis or fistulas were detected within a median follow-up period of 62 months (range 1-164 months). CONCLUSIONS The poppy seed test is the most reliable diagnostic method for the detection of colovesical fistulas. The one-stage resection of the fistula of the colon and bladder segment without protective colostomy is safe and feasible.

Metastasized prostate cancer. Position paper on the use of chemotherapy

BACKGROUND Antihormonal and cytotoxic therapy options are available for the therapy of metastasized prostate cancer (mPC). Because no comparative studies are available, especially for castration-resistant prostate cancer (mCRCP), it remains unclear which patients will profit best from which therapy. OBJECTIVES Previous data on the sequence of the various therapy options show that correct selection of the first line therapy for mCRPC can have an influence on the prognosis of the patient. In this position paper the various therapy options are critically illustrated and the clinical and pathohistological criteria for selection of the first line therapy of mCRPC are discussed. RESULTS Molecular markers are an important aid for future patient selection and individualized therapy for optimal use of the available forms of therapy.

Kontinente Harnableitung nach vorderer Exenteration

BACKGROUND Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir). RESULTS Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field. CONCLUSION Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).

Robot-Assisted Transvesical Enucleation of Benign Prostatic Hyperplasia: Lessons from a Single Surgeon’s Learning Curve

Introduction: Open simple prostatectomy is a well‐established and effective operation for prostate volumes greater than 80 gm but also associated with bleeding and urinary incontinence. To benefit from the advances of laparoscopy, robot‐assisted simple prostatectomy was established. We determined the learning curve of this minimally invasive surgery by evaluating the first procedures by an experienced robotic surgeon. Methods: Patients presenting for surgical therapy with prostate volumes greater than 80 gm were considered for the study. Evaluation included validated questionnaires preoperatively, and at 6 and 12 weeks postoperatively. Blood loss, transfusions, operation time and pad use after catheter removal were documented. The experience based on the results from 18 cases treated with robot‐assisted simple prostatectomy by one of us (JWT) is presented. Results: Mean age of the 18 patients was 71.2 years, mean enucleated prostate volume was 91 gm and mean preoperative flow was 9.0 ml/second. I‐PSS and QoL values improved significantly from 25 to 6.1 (p <0.005) and from 5 to 1.1 (p <0.005), respectively, and flow rate increased to 28.2 ml/second (p <0.005) postoperatively. There were no significant changes in sexual performance based on IIEF (p = 0.73). Of the 18 patients 14 had complete continence immediately after catheter removal, and at 6 weeks postoperatively 17 were completely continent. Decreases in operation time from 250 to 150 minutes and blood loss from 400 to 200 ml were noted after 5 procedures. Only minor complications occurred and 1 patient required transfusion postoperatively (Clavien‐Dindo II). Conclusions: Robot‐assisted simple prostatectomy is a safe and effective operation for benign prostatic hyperplasia, which can be learned with good results in a rather short time.

Perioperatives Outcome in Korrelation zur Lernkurve bei robotisch assistierter partieller Nephrektomie: Die ersten 109 Fälle unserer Klinik

BACKGROUND In contrast to conventional laparoscopic partial nephrectomy, the approach of robot-assisted partial nephrectomy (RAPN) shows a steep learning curve with shorter warm ischaemia times (WIT) and comparable postoperative outcomes. Therefore RAPN is considered a good minimally-invasive surgical procedure for patients presenting with a renal cell carcinoma in clinical stage cT1a. The aim of the presented study was to evaluate the perioperative outcomes of our patients after RAPN and to illustrate the learning curve based on characteristic perioperative parameters such as WIT. MATERIAL AND METHODS The data of 109 patients treated by RAPN in our clinic between January 2010 and April 2015 were retrospectively analysed regarding perioperative, laboratory and oncological outcomes. Postoperative complications until 30 days after surgery were documented. We analysed the data of the largest patient population treated by a single urologist, comparing WIT, operating time, blood loss and decline of the glomerular filtration rate between the first and the second 30 consecutive cases. RESULTS Mean WIT was 18.4 min (SD±10.2), mean operating time was 199 min (SD±20), and mean estimated blood loss was 657 millilitres (SD±715 ml). Mean loss of GFR was reported to be 4.99 mg/dl/1.73 m (2) (SD±15.44). 83 (76%) malignant lesions were removed. 11 patients (10%) had a R1 resection, one patient had a R2 resection and in 2 cases the resection status was Rx. 22% of patients developed postoperative complications. Intraoperative complications were documented in 2 cases. According to the Clavien-Dindo Classification, 6% of patients had grade 1 and 2 complications and 13% developed grade 3 and 4 complications. WIT was significantly lower after 30 consecutive cases treated by one urologist. Regarding operating time, GFR or blood loss no significant correlation was found. CONCLUSION Our data is in line with the surgical outcomes described in the literature. RAPN is a safe surgical technique with a steep learning curve. In our experience, 30 surgical cases provide a urologist with sufficient expertise to achieve good perioperative results. Weaknesses of this report include the retrospective design and insufficient documentation in some cases.

Continent urinary diversion following anterior exenteration

BACKGROUND Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir). RESULTS Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field. CONCLUSION Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).

Kontinente Harnableitung nach vorderer Exenteration@@@Continent urinary diversion following anterior exenteration

BACKGROUND Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir). RESULTS Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field. CONCLUSION Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).