Dominik Abt

Therapeutic options for intractable hematuria in advanced bladder cancer

Intractable hematuria is a common and severe complication in patients with inoperable bladder carcinoma. The aim was to provide an overview of therapeutic options for such cases, and analyze their effectiveness and risk profile, so a systematic literature search of peer‐reviewed papers published up to September 2012 was carried out. Various options are available to treat hematuria in patients with inoperable bladder cancer; these include orally administered epsilon‐aminocaproic acid, intravesical formalin, alum or prostaglandin irrigation, hydrostatic pressure, urinary diversion, radiotherapy, embolization and intraarterial mitoxantrone perfusion. These treatment options are associated with different prospects of success, risks and side‐effects. Well‐designed and large studies comparing options are completely lacking. Despite various treatment options, management of intractable hematuria in patients with inoperable bladder cancer remains a challenge, and most of the reported methods should be seen as experimental. Interventional radiology and alum instillation seem to be suitable alternative options for patients who, after critical consideration, cannot be treated by irrigation, transurethral resection or palliative cystectomy.

Bipolar versus Monopolar Transurethral Resection of the Prostate: Results of a Comparative, Prospective Bicenter Study – Perioperative Outcome and Long-Term Efficacy

Objectives: To compare bipolar and monopolar transurethral resection of the prostate (TURP) in a comparative prospective study at two urology centers. Methods: Of 212 patients with symptomatic benign prostatic hyperplasia entered prospectively into the study, 111 underwent bipolar and 101 monopolar TURP. Patients were treated in two consecutive series with each surgical method at both centers. Improvement in peak flow rate, postvoid residual, International Prostate Symptom Score, and quality of life score postoperatively and at 3, 12, 24 and 36 months, as well as long-term adverse events were compared. Regarding safety, duration of surgery, postoperative catheterization and hospitalization time, amount of fluid absorption, frequency of transurethral resection (TUR) syndrome, and risk of hemorrhage were evaluated. Results: Patient characteristics of the two series were comparable. The risk of developing TUR syndrome (p = 0.32) and bleeding tendency (p = 0.52) did not differ significantly between groups. Significant differences were seen for duration of surgery and resection speed. All functional parameters improved significantly during follow- up, with no relevant differences between surgical groups. Conclusions: Since no major differences in efficacy and safety were seen between the surgical groups, we feel that the monopolar technique still has a valuable place in TURP.

Prevention and treatment of symptoms associated with indwelling ureteral stents: A systematic review

Temporary drainage of the upper urinary tract by internal ureteral stents is a routine procedure in endourology. However, it is associated with a clear side‐effect profile. Our aim was to evaluate prevention and treatment options of stent‐related symptoms. We carried out a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines using MEDLINE and SCOPUS, and identified 107 appropriate records. A high number of these studies showed clear methodological limitations. Available data clearly support the use of α1‐blockers in patients suffering from stent‐related symptoms. It seems that antimuscarinic monotherapy or combination with α1‐blockers might also play an important role, whereas the use of classical analgesics in the treatment of stent‐related symptoms has not been assessed systematically within clinical trials so far. Improvements in stent design and material seem to have the potential to reduce stent‐related symptoms. However, so far there is no type of stent with outstanding characteristics and clear evidence suggesting fundamental advantages compared with a standard double pigtail stent. Although stent diameter does not seem to influence patients’ comfort, it seems to be beneficial to choose a proper stent‐length. Coated and drug‐eluting stents, as well as intravesical drug application, seem to be promising concepts to prevent stent‐related symptoms, but still have to be considered as experimental approaches. Furthermore, thorough patient education has the potential to reduce the morbidity associated with ureteral stenting. Further research in the field seems to be mandatory.

Is intravesical stent position a predictor of associated morbidity

Purpose Temporary drainage of the upper urinary tract by use of internal ureteral stents is a common procedure that is often associated with a variety of symptoms. The role of intravesical stent position in associated morbidity is controversial. Materials and Methods The German version of the ureteral stent symptom questionnaire (USSQ) was completed by 73 patients with an indwelling ureteral stent the day before stent removal. Intravesical stent position was classified into 3 categories by x-ray before stent removal. The influence of intravesical stent position on USSQ score was analyzed, including subscores and single items. Results Intravesical stent position showed no significant influence on associated morbidity. The median USSQ total score in all patients was 77.5 (range, 30-147). Patients with ipsilateral stents (69.0; range, 30-122) tended to have lower total scores than did those with tangential (86.5; range, 30-122) or contralateral (77.0; range, 31-147) stents, but the differences were not statistically significant (p=0.35). The USSQ subscores for urinary symptoms (p=0.80), body pain (p=0.80), general health (p=0.16), work performance (p=0.07), additional problems (p=0.81), and all of the USSQ single items of interest in the context of stent length also did not differ significantly between the three groups. Conclusions Intravesical stent position did not significantly influence associated morbidity in our study. An appropriate stent length should be chosen to avoid dislocation. However, complex calculations of optimum stent length, time-consuming manipulations, and costly stock holding of various stent sizes to obtain the perfect stent position do not seem worthwhile.

Economic Aspects of Morbidity Caused by Ureteral Stents.

Objective: To assess the economic burden of temporary ureteral stenting. Methods: The German version of the ureteral stent symptom questionnaire was completed by 74 patients with unilateral inserted indwelling stents. Cost accounting was performed considering the costs of ureteral stents, drugs, consultation of healthcare professionals, hospitalization, stent extraction and work incapacity due to stent-related problems. Results: Total costs arising from stent-related problems amounted to US dollars (USD) 133,355, median USD 455 (113-11,948) for the entire stent indwelling time, and USD 15 (4-398) per patient per day. Costs (USD total/median (range)) arose mainly from work incapacity (104,154/0 (0-11, 498)), followed by healthcare professional consultation (9,177/0 (0-612)), drug costs (8,736/111 (0-427)), stent material (8,390/113), stent removal (2,235/0 (0-1,769)) and outpatient hospital care (663/0 (0-663)). Most patients also showed a reduced capacity for work due to symptoms associated with indwelling stents. Conclusion: The economic burden of morbidity associated with indwelling ureteral stents is considerably high and should be taken into account when performing ureteral stenting, especially in cases where it is not strictly indicated and when stent removal is scheduled.

Influence of patient education on morbidity caused by ureteral stents

To investigate the influence of patient education on symptoms and problems caused by ureteral stents.

Biofilm formation on ureteral stents - Incidence, clinical impact, and prevention

Ureteral stents are a simple, minimally invasive method of maintaining ureteral drainage to assure renal function, treat pain caused by ureteral obstruction and avoid external or visible devices. Ureteral stenting is, however, associated with a clear side-effect profile, including irritation on voiding, pain and haematuria. Complications such as stent dysfunction and clinically significant urinary tract infections are also regularly observed. Although this has not yet been thoroughly researched, it appears that biofilm formation on ureteral stents plays a key role in the associated morbidity. In this review, we summarise the current evidence and identify areas that should be further studied to reduce the morbidity associated with ureteral stenting.

Soft tissue sarcomas of the kidney.

Soft tissue sarcomas are rare mesenchymal tumors. Amongst others, primitive neuroectodermal tumors (PNET) of the kidney and synovial sarcoma of the kidney belong to the group of soft tissue sarcomas. Synovial sarcomas can occur almost anywhere in the body, most frequently, however, in the lower (62%) or upper extremities (21%). Metastases occur in 50-70% of cases, and thus the prognosis is poor. PNETs are rare, highly aggressive neoplastic lesions which mainly occur in the torso or axial skeleton in young adults. The prognosis is poor with a 5-year disease-free survival rate of 45-55%. The primary therapeutic approach is surgical resection. Most randomized studies assessing adjuvant chemotherapy for all types of localized soft tissue sarcomas did not show statistically significantly better overall survival times after chemotherapy, although they did show longer progression-free survival. We report on two cases of primary renal synovial sarcoma and one case of PNET of the kidney.

Consecutive Spontaneous Rupture of the Lower Pole Renal Artery and Main Renal Artery Due to Type 1 Neurofibromatosis

We report on a 37-year-old man suffering from type 1 neurofibromatosis with spontaneous rupture of a lower pole artery of the right kidney. Two renal arteries with aneurysmal alterations were identified at angiography. We did not coil the lower pole artery because active bleeding had stopped. Eleven days later, the patient suffered a further spontaneous rupture to the right main renal artery, and nephrectomy was unavoidable. His recovery was rapid and unremarkable.

Readability Assessment of Patient Education Material Published by German-Speaking Associations of Urology

Objective: To assess the readability and comprehensibility of web-based German-language patient education material (PEM) issued by urological associations. Materials and Methods: German PEM available in June 2017 was obtained from the European Association of Urology (EAU), German (DGU), Swiss (SGU) and Austrian (ÖGU) Association of Urology websites. Each educational text was analyzed separately using 4 well-established readability assessment tools: the Amstad Test (AT), G-SMOG (SMOG), Wiener Sachtextformel (WS) and the Lesbarkeitsindex (LIX). Results: The EAU has issued PEM on 8 topics, the DGU 22 and the SGU 5. The ÖGU refers to the PEMs published by the DGU. Calculation of grade levels (SMOG, WS, LIX) showed readability scores of the 7th-14th grades. The easiest readability was found for materials on Nocturia and Urinary Incontinence issued by the EAU. Kidney Cancer and Infertility, issued by the DGU had the hardest readability. The EAU achieved the best median AT score, followed by the SGU, and the DGU. Conclusion: Remarkable differences between readability were found for the PEMs issued by EAU, DGU and SGU. Materials published by the EAU were the easiest to read. Improving the readability of certain PEMs is of crucial importance to meet patient needs and act in the interests of a growing, self-informing German-speaking patient community.