Clemens Brössner

Endocrine status in elderly men with lower urinary tract symptoms: correlation of age, hormonal status, and lower urinary tract function

OBJECTIVES To correlate endocrine parameters in elderly men with lower urinary tract symptoms (LUTS) to patient age and clinical parameters such as prostate volume, prostate-specific antigen (PSA) levels, and uroflowmetry and to compare the clinical and endocrinologic parameters in men with or without hypogonadism. METHODS Men (40 years old or older) with untreated LUTS as defined by an International Prostate Symptom Score (IPSS) of 7 or greater due to benign prostatic hyperplasia were included in this study and underwent the following investigations: IPSS, free uroflow study, postvoid residual volume, transrectal ultrasound for assessment of prostate volume, serum PSA determination, and an endocrine study, including testosterone, human luteinizing hormone, human follicle-stimulating hormone, prolactin, dehydroepiandrostendione-sulphate (DHEA-S), and prolactin. RESULTS Three hundred twelve men (mean age 62.8 +/- 10.6 years, range 40 to 91) were analyzed. The serum levels of estradiol (correlation coefficient [r] = 0.19), human luteinizing hormone (r = 0.32), human follicle-stimulating hormone (r = 0.19), and DHEA-S (r = -0.39) correlated (P <0.05) with age; no such correlation was seen for testosterone (r = 0.04; P0.05) or prolactin (r = 0.09; P0.05). Estradiol (but not testosterone) correlated (r = 0.17, P = 0.01) with prostate volume. The peak flow rate and PSA did not correlate with any endocrinologic parameter. Hypogonadism (serum testosterone less than 3.0 ng/mL) was detected in 22.1% of patients and had no impact on clinical (IPSS, peak flow rate, prostate volume, and PSA level) or endocrine (human luteinizing hormone, human follicle-stimulating hormone, estradiol, prolactin, and DHEA-S) parameters. CONCLUSIONS A number of age-related endocrine changes are seen in elderly men with LUTS. Hypogonadism is seen in approximately one fifth of elderly men with LUTS, but in our study it had no impact on symptom status, PSA level, prostate volume, uroflowmetry, or endocrine parameters.

Does extended lymphadenectomy increase the morbidity of radical cystectomy

To report the events during and after radical cystectomy and urinary diversion for bladder cancer, in terms of major and minor complications, comparing a minimal with an extended lymphadenectomy, as more lymph nodes obtained during radical cystectomy may improve staging and thus the outcome.

Lymphatic drainage of prostatic transition and peripheral zones visualized on a three-dimensional workstation

OBJECTIVES To determine whether the prostate has lymphatic/lymph node drainage that is not sampled by conventional lymphadenectomy and whether the transition and peripheral zones of the prostate have a different lymphatic drainage, because up to one quarter of lymph-node-negative patients who undergo radical prostatectomy will develop distant metastases. METHODS Ten patients (mean age 62.3 years, range 50 to 76) scheduled for transrectal ultrasound-guided sextant biopsy because of an elevated serum prostate-specific antigen level of 4 to 10 ng/mL and a normal digital rectal examination were included in this study. All patients underwent ultrasound-guided sextant biopsies. Subsequently, an oily contrast medium was injected into the transition zone (group A, n = 5) or peripheral zone (group B, n = 5) of the prostate under transrectal ultrasound guidance and fluoroscopy. Immediately, 1 hour, and 24 hours after the procedure, anteroposterior and lateral radiographs were obtained. In addition, spiral computed tomography of the abdomen was performed 10 minutes after the procedure and analyzed on a three-dimensional workstation. RESULTS No difference in the lymphatic drainage system between the transition and peripheral zones of the prostate was found. In all patients (n = 10), the lymphatic drainage comprised three major routes: (1) the prostate to the lymph nodes along the lateral bony wall of the pelvis to the angle of internal/external iliac lymph nodes to the common iliac lymph nodes, (2) the prostate to the perineal floor to the pudenda internal lymph nodes to the angle of the internal/external iliac lymph nodes to the common iliac lymph nodes, and (3) the prostate to the sacral lymph nodes. In all 10 patients, main contrast medium enhancement was seen immediately after procedure indicating drainage from the prostate to the lymph nodes along the lateral bony wall of the pelvis. Presacral lymph node enhancement was seen in all patients only in the late (24 hours after contrast injection) radiograph. CONCLUSIONS Our data suggest that the main lymphatic drainage, irrespective of the prostatic region (transition or peripheral zone), runs to the pelvic regions that are mostly removed by standard lymphadenectomy techniques. However, one has to bear in mind that the prostate has some lymphatic drainage that is not covered by standard lymphadenectomy and therefore carries the risk of metastatic tumor spread.

Twelve prostate biopsies detect significant cancer volumes (> 0.5 mL)

Objectives To compare, in a retrospective study, pathological specimens of prostate cancer detected in additional areas of a 12‐core biopsy with tumours detected using traditional sextant biopsy.

Comparative Study of Two Different TRUS–Guided Sextant Biopsy Techniques in Detecting Prostate Cancer in One Biopsy Session

Objective: The aim of this study was to compare a transrectal ultrasound (TRUS)–guided sextant biopsy technique, which puts more emphasis on the apical region of the prostate where most prostate carcinomas (PCs) develop, with the standard sextant biopsy technique.Methods: A total of 280 patients with suspected PC were included in this analysis. Twelve biopsy cores were obtained from all patients. Six biopsy cores were taken within a lateral parasagittal plane from each lobe at the apex, middle and basis, with an angle of approximately 45° (technique A), and 6 further biopsy cores were taken from the left to the right lateral margin always penetrating the prostate in the apex with the same angle (socalled fan–shaped technique, technique B). Technique A predominantly samples in the sagittal and technique B samples more in the transversal plane with emphasis on the apical region where most PCs develop. The sensitivity in detecting PCs for both techniques was calculated and correlated to the serum prostate–specific antigen (PSA) levels.Results: A total of 72 PCs (25.7%) were diagnosed. We subsequently performed subgroup analysis depending on the serum PSA levels: in patients with a PSA of ≤10 ng/ml (n = 27) technique A has a PC sensitivity of 88.8% (p = 0.037) and technique B 96.2% (p = 0.326) as compared to our reference standard of 100% by sampling 12 biopsy cores in the same prostate. The number of positive biopsy cores using technique B was superior in 12 cases as compared to 3 cases with technique A (p = 0.04). In 12 patients the number of positive biopsy cores was identically. In patients with a PSA of >10 ng/ml (n = 45) technique A has a PC sensitivity of 93.3% (p = 0.083) and technique B 88.8% (p = 0.023) as compared to our reference standard. The number of positive core biopsies using technique A was superior in 14 cases as compared to 12 with technique B (p = 0.154). In 19 patients the number of positive biopsies was identical.Conclusion: Our data suggest that in patients with PSA of ≤10 ng/ml technique B bring significant benefit with regard to the number of positive core biopsies, as well as an enhanced PC detection rate which is near the 12–core biopsy. Due to the fact that technique B samples more in the apical region where most cancers develop, it should be performed in suspected early stage cancers of the prostate (PSA≤10 ng/ml).

Long-term outcome of the adjustable transobturator male system (ATOMS): results of a European multicentre study.

To evaluate the long‐term effectiveness and safety of the adjustable transobturator male system (ATOMS®, Agency for Medical Innovations A.M.I., Feldkirch, Austria) in a European‐wide multicentre setting.

Risk Factors for Treatment Failure With the Adjustable Transobturator Male System Incontinence Device: Who Will Succeed, Who Will Fail? Results of a Multicenter Study

OBJECTIVE To identify risk factors for treatment failure of men with the adjustable transobturator male system (ATOMS) for treating stress urinary incontinence (SUI). PATIENTS AND METHODS Sixty-two patients with SUI after prostate surgery were provided with an ATOMS. The self-defined criteria for treatment failure (implant removal [A], no improvement or ≥3 pads/24 hours [B], and no improvement or ≥150 mL urine loss/24 hours [C]) were compared to anamnestic, clinical, and time-specific parameters: age, Charlson comorbidity index (CCI), urine culture (UC), previous ineffective implants, body mass index, radiotherapy, renal function (serum creatinine), smoker status, urethral strictures, SUI severity, surgery time, time to and season at implantation, and port system application. RESULTS After a median follow-up of 17.7 months, 9 ATOMS (15%) were removed due to infection (8) or dysfunction (1); 23% and 16% had treatment failure of criteria B and C. Dry rate/overall success rate was 61%/87%. Age alone was no risk factor but the CCI and a positive UC were univariate significant predictors of the criteria A, B, and C. Besides, previous devices and renal failure were significantly associated with implant removal (A) and SUI severity with criterion C. In multivariate analysis, previous devices (P = .0163), positive UC (P = .0190), and SUI severity (P = .0123) were the strongest predictors of A, B, and C, respectively. CONCLUSION A poor CCI, preoperative positive UC, severe SUI, and previous implants lead to more treatment failure and removal. Age, body mass index, radiotherapy, urethral strictures, current smoking, time-specific parameters, seasonality, and port system application did not influence the outcome.

Radical Cystectomy for Bladder Cancer in the 70+ Population: A Nation-Wide Registry Analysis of 845 Patients

Aim: To analyze demographics, perioperative mortality and overall survival of radical cystectomy (RC) in patients aged 70+ years in Austria in a nation-wide registry cohort. Patients and Methods: All patients >69 years who underwent RC in public hospitals (covering >95% of all surgical procedures) in Austria between 1992 and 2004 were analyzed. Data were provided by the Austrian Health Institute (ÖBIG). Results: A total of 845 patients aged 70–89 years (mean 74) entered the analysis. The annual number of cystectomies in this age group increased from 27 in 1992 to 79 (+292%) in 2004. The mean length of hospital stay declined from 37.1 days (in 1992) to 27.1 days (in 2004). The 60-day mortality of the entire cohort was 1.5% and increased to 5.2% in patients aged 80+ years. Almost 50% of patients had to be rehospitalized within 30 days. The 5-year overall survival declined from 62% in those aged 70–74 years to 61% in those aged 75–79 years to 46% in the oldest age group (80+ years). Conclusions: The annual number of cystectomies in patients aged 70+ years increased substantially during the study period. These nation-wide registry data provide insights into the current status of RC in the elderly in Austria and demonstrate that cystectomy in this age cohort can be done with an acceptable perioperative mortality and overall survival.

Prostatic Phyto-Oestrogen Tissue Levels in Different Austrian Regions

Introduction: A number of studies suggest that the low incidence of prostate cancer as well as benign prostatic enlargement in Asia depends on the extended consumption of phyto-oestrogens in these parts of the world. In most Asian men, phyto-oestrogen levels are multiple higher compared to Austrian (European) men. The aim of our study was to evaluate, according to the East-West decline, whether there were significant differences within the Austrian population. We compared prostate phyto-oestrogen tissue levels of men living in three different geographical regions of Austria. We further compared men living in rural and urban environments. Material and Methods: Prostatic tissue samples of 103 men undergoing surgery for benign prostatic hyperplasia or prostate cancer were collected and frozen at –40°C. In tissue samples, enterolactone (representative for lignans) and genistein levels (representative for isoflavones) were determined in duplicate by monoclonal antibody-based immunoassays. We subsequently compared tissue levels of men living in rural and urban environments and different geographical regions of Austria. Results: Prostatic enterolactone tissue levels were similar in men living in an urban (median 19.1 ng/g dry weight, range 1.5–76.4) or rural environment (median 15.7 range 0.6–140.6) p = 0.99. The respective values for genistein were 20.5 ng/g dry weight (range 4.6–47.4) and 9.3 (range 0.1–156.7) p = 0.77. Furthermore, enterolactone (p = 0.1) and genistein (p = 0.65) levels were similar in three different geographic regions in Austria. Conclusion: No significant differences regarding genistein and enterolactone were found between our study populations. However, we found a wide variation between individual patients.

Holmium laser-enucleation of the prostate enables early catheter removal

TURP is still considered the standard surgical therapy for patients with severe LUTS caused by benign prostatic obstruction refractory to medical therapy, or in those with an absolute indication for surgery [1]. Recently holmium laser enucleation of the prostate (HoLEP) has been established as a minimally invasive procedure giving a comparable clinical outcome to that after conventional TURP and open prostatectomy [2–5]. A major advantage of HoLEP is the excellent haemostasis when the holmium laser beam (at 2140 nm) is defocused [2]. This excellent haemostasis provides the theoretical possibility of early catheter removal. Thus we tested this possibility in a consecutive series of patients undergoing HoLEP.