Gerhart Hubmer

Is repeated transurethral resection justified in patients with newly diagnosed superficial bladder cancer

OBJECTIVES To assess the value of repeated transurethral resection (TUR) in patients with newly diagnosed superficial bladder cancer. METHODS A second TUR was performed in 110 consecutive patients (24 women and 86 men) with newly diagnosed superficial bladder cancer. The mean age was 66 years (range 30 to 85). A second TUR was performed within 4 to 6 weeks after the initial TUR. After the first TUR, the pathologic stage was pTa in 31 patients (28%), pT1 in 76 (70%), and carcinoma in situ in 3 (2%). The pathologic records of the second TUR were reviewed and compared with the findings of the first operation. RESULTS Cystoscopy before the second TUR was negative in 79 patients. Of these cases, 14 (17.7%) had cancer histologically. The second TUR was negative in 70 patients (63.6%). Twenty-two (20%) had residual cancer of the same stage, 9 (8.2%) had a lower stage, and 9 (8.2%) had a higher stage. Of 31 patients with Stage pTa and 76 patients with Stage pT1 at the first TUR, 19 (61.3%) and 51 (67.1%) had a negative second TUR, respectively. CONCLUSIONS We recommend a second TUR for patients with superficial bladder cancer for several reasons. A negative second TUR provides important prognostic information. In addition, removal of residual cancer is achieved early. Finally, patients with pT1 G3 tumors are at high risk of residual, or even invasive, cancer and should be offered definitive therapy as early as possible.

Patient Self-Reporting Questionnaire on Urological Morbidity and Bother after Radical Retropubic Prostatectomy

OBJECTIVES We assessed the incidence of morbidity and bother on quality-of-life (QL) after radical retropubic prostatectomy for prostate cancer. METHODS At least 12 months after surgery, self-reporting questionnaires were completed and returned by 368 (77.8%) of 473 eligible patients. Surgery related morbidity was evaluated by adhoc constructed questions. QL was assessed by the European Organization for Research and Treatment of Cancer QL core questionnaire (EORTC QLQ-C30). Multivariate and univariate analysis as well as regression analysis were used to assess the bother factors. RESULTS Postoperative urinary incontinence significant enough for the patient to use some kind of protection was reported by 27.2%. After surgery, 14.2% of preoperative potent men were able to get and maintain an erection sufficient enough for sexual intercourse without any aid. Overall 10.6% of respondents had undergone surgery for anastomotic stricture and 23.6% reported on adjuvant therapy. Furthermore, 43.2% reported on fear of not being cured from cancer. Postoperative urinary incontinence and fear of not being cured were associated with significant lower global QL scores and turned out as independent predictors for global QL. In contrast, postoperative erectile dysfunction, anastomotic stricture and adjuvant therapy were not independent predictors. In addition, 82.1% would vote for surgery again. CONCLUSION The majority of the patients would opt for surgical treatment again, although morbidity is common after radical prostatectomy and may impair QL. Particularly urinary incontinence and fear of not being cured are independent predictors for global QL after surgery. Therefore, surgical techniques with a low morbidity are requested as well as some kind of psychological support in order to cope with existential fear.

Impact of tumor-associated symptoms on the prognosis of patients with renal cell carcinoma: a single-center experience of 683 patients

OBJECTIVES To evaluate the impact of cancer-associated symptoms present at the diagnosis of renal cell carcinoma (RCC) on the prognosis of patients. Increasing numbers of RCC are currently detected incidentally by routine ultrasonography. METHODS From January 1994 to December 2000, 693 operations for RCC in 683 consecutive patients have been performed at our institution. Overall, tumor-specific, and progression-free survival were investigated using the Kaplan-Meier method. For multivariate analysis regarding tumor-specific survival, the Cox regression model, including risk ratios, was used. A receiver operating characteristics curve regarding the sensitivity and specificity for the association between tumor size and symptoms was used. RESULTS Of the 683 patients, 417 patients were male and 266 female. The mean patient age was 62 years (range 16 to 88). Of the 683 patients, 141 (20.8%) presented with symptoms suspicious for cancer. The 5-year overall, progression-free, and cancer-specific survival rates were 82%, 79%, and 86%, respectively, for asymptomatic patients compared with 60%, 55%, and 65%, respectively, for patients with symptoms at diagnosis (P <0.0001, log-rank test). The cutoff value of 5 cm for the tumor diameter to result in symptoms was chosen on the receiver operating characteristic curve. Multivariate analysis found tumor grade (P = 0.001), tumor stage (P = 0.001), presence of symptoms (P = 0.013), and tumor diameter (P = 0.005) to be independent prognostic parameters for cancer-specific survival. CONCLUSIONS Tumors larger than 5 cm were significantly more likely to cause symptoms compared with smaller tumors in our series. In multivariate analysis, patients presenting with symptoms suspicious for cancer at the diagnosis of RCC had a 1.8-fold greater risk of dying of cancer compared with patients without symptoms.

Did the rate of incidental prostate cancer change in the era of PSA testing? A retrospective study of 1127 patients

OBJECTIVES To evaluate, in a retrospective study, the impact of routine prostate-specific antigen (PSA) testing on the rate of incidental prostate cancer in patients undergoing surgery for obstructive symptoms caused by presumed benign prostatic enlargement (BPE) and to investigate the indication of a routine biopsy before alternative treatment procedures for BPE. In the pre-PSA era, the diagnosis of incidental carcinoma was exclusively based on normal digital rectal examination (DRE) findings. METHODS Since January 1993, 2422 operations (2283 transurethral resection of the prostate, 139 retropubic adenoma enucleations) for BPE were performed at our institution. The preoperative DRE findings and PSA level were evaluated, and patients with any suspicion for cancer were excluded. The pathologic reports of all patients were reviewed. A diagnosis of incidental carcinoma of the prostate required histologic evidence of cancer and negative DRE findings and a PSA level within age-specific reference ranges preoperatively. RESULTS Of 2422 patients, 1127 (46.5%) had both negative DRE findings and an age-specific PSA level and were evaluated for our study. Overall, prostate cancer was diagnosed by surgery in 314 (13%) of 2422 patients. The rate of incidental prostate cancer in patients with both negative age-specific PSA levels and negative DRE findings was 6.4% (72 of 1127). CONCLUSIONS In our series, the likelihood of detecting incidental prostate cancer by surgery was 6.4%. In the PSA era, the rate of incidental prostate cancer has been decreased by more than 50%. Today, the low rate of incidental carcinoma does not warrant routine histologic evaluation of the prostate if PSA testing and DRE are negative when alternative treatment modalities without tissue sampling are offered for the treatment of BPE.

Detection of prostate cancer by TURP or open surgery in patients with previously negative transrectal prostate biopsies

OBJECTIVES To evaluate retrospectively the effectiveness of transurethral resection of the prostate (TURP) in diagnosing prostate cancer in patients with obstructive voiding symptoms and a history of negative transrectal prostate biopsy but elevated prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE). METHODS In 1189 consecutive patients undergoing TURP or open prostatectomy between 1994 and 2000 for obstructive voiding symptoms, we identified 445 patients (37.4%) with at least one previous set of transrectal prostate biopsies because of an elevated PSA level and/or abnormal DRE findings. The probability to detect prostate cancer by TURP (n = 423; 95%) or open surgery (n = 22; 5%) was investigated overall, as well as related to patient age, PSA level, DRE findings, number of previous biopsies, time from biopsy to surgery, and weight of resected tissue. RESULTS The mean number of preoperative negative biopsies per patient was 1.6 (range 1 to 8). The mean patient age was 69 years (range 48 to 89). The median PSA level and resection weight was 8.64 ng/mL and 32 g, respectively. Ninety-seven patients (21.8%) had abnormal DRE findings. Overall, prostate cancer was detected in 35 patients (7.9%). The cancer incidence was 5.5% (19 of 348) in patients with a normal DRE compared with 16.5% (16 of 97) in patients with an abnormal DRE (P <0.001; Fishers exact test). The cancer rate was also related to age; other subgroups showed no statistically significant differences regarding cancer incidence. CONCLUSIONS In patients with previously negative biopsies, the diagnostic yield of TURP is low. Therefore, TURP for diagnostic purposes only cannot be recommended. However, in patients with an abnormal DRE and obstructive symptoms, surgery should be preferred over alternative treatment options.

Long-term results of nephron-sparing surgery for renal cell carcinoma in 114 patients: risk factors for progressive disease

To evaluate risk factors for metastatic disease after nephron‐sparing surgery (NSS) for renal cell carcinoma (RCC).

Outcome and Safety of Extracorporeal Shock Wave Lithotripsy as First-Line Therapy of Lower Pole Nephrolithiasis

Introduction: The aim of this study is to assess the efficiency of extracorporeal shock wave lithotripsy (ESWL) as initial therapy for isolated lower pole kidney stones smaller than 20 mm. Patients and Methods: During a 24-month period 116 patients with previously untreated single stones under 20 mm in diameter were treated with a Dornier lithotripter S. They were analyzed with regard to stone site and size, number of ESWL sessions, auxiliary measures, retreatment rates, complications and the time taken for stone clearance. Results: 76 patients (65.5%) became stone free, 50 of them (43.1%) within 3 months after ESWL. Depending on stone size the stone-free rates were 67.1% for patients with a stone diameter of <10 mm (59 of 88 patients), and 60.7% for stone diameters between 10 and 20 mm (17 of 28 patients). Complications during and after treatment were rare, i.e. the necessity of ureteral stent insertion due to colic (n = 10), endoscopic stone removal (n = 2), acute pyelonephritis (n = 1), stonestreet (n = 1) and 1 case of hematoma not requiring intervention. The recurrence rate during follow-up (13.2–36.9, mean 25.0 months) was low: 16 patients (13.8%) had recurrent or persistent stones, and 74 patients (63.8%) had no evidence of urolithiasis. Conclusions: ESWL is a safe and efficient first-line therapy for treatment of isolated small lower pole kidney stones with acceptable stone-free rates, low morbidity, few complications and a low stone recurrence rate.

Fournier's gangrene after tension-free vaginal tape (TVT) procedure.

A 78-year-old woman presented at the outpatient clinic of a peripheral urological department with oliguria and genital pain. Medical history showed that in 1996 she had had a vaginal hysterectomy combined with anterior and posterior colporrhaphy. In April 2002 she underwent anterior colporrhaphy, sacrospinal fixation of the vagina (Amreich–Richter procedure) and TVT insertion at a gynecology department because of urodynamic stress incontinence (USI) and prolapse of the anterior vaginal wall. Five weeks later the primary TVT was removed because of recurrent USI and a new one was inserted. Two weeks later, on admission, clinical examination showed a marked swelling and a brown livid discoloration of the mons pubis spreading to the left labium majus. Laboratory examination revealed anemia and elevated kidney and inflammatory parameters (creatinine 2.54 mg/dl (normal laboratory value 0.6–1.3), urea 55.6 mg/dl (10–45) and C-reactive protein 35.6 mg/l (0-8)). Computed tomography (CT) imaging of the pelvis showed a marked accumulation of gas in the pubic region and left labium majus, as well as a moderate hematoma in the small pelvis (Fig. 1). Under suspicion of clostridial necrosis she immediately underwent debridement and drainage of the affected area. The next day she was transferred in a poor general condition with artificial ventilation to our clinic for hyperbaric oxygen therapy (HBO). At this time clinical examination showed swelling and edema of the whole pubic region and the labia majora, with subcutaneous necrosis and demarcated gangrene around the drainage (Fig. 2a). Extensive necrectomy, removal of the tape and drainage of the paravesical space was performed (Fig. 2b). Histological examination showed an acute phlegmonous and abscess-forming inflammation. Subsequently she underwent several HBO sessions. Wound smears showed staphylococcus in masses, anaerobes and Bacteroides species, and therefore the initially administered antibiotic (penicillin) was changed to imipenem and fosfomycin, according to the antibiogram. Immediately postoperatively the patient had a central venous catheter placed, which caused perforation of the right subclavian artery with mediastinal bleeding. This lesion was successfully covered angiographically using a Wall’s stent. On the first postoperative day she twice underwent successful electrocardioversion for tachycardic fibrillation. Intermittently she suffered acute renal failure. On the fourth postoperative day she was extubated after a renewed necrectomy. Control CT and magnetic resonance (MR) imaging revealed moderate regression. Two weeks later the wound showed good granulation. The patient was transferred to the department of plastic surgery for reconstruction (Fig. 3). Her further course was uneventful. After removal of the indwelling catheter she showed grade 3 USI.

Do patients with a higher body mass index have a greater risk of advanced-stage renal cell carcinoma?

OBJECTIVES To evaluate whether patients with a higher body mass index (BMI) are at elevated risk of an advanced tumor stage for renal cell carcinoma at diagnosis. A high BMI has recently been proved to be associated with advanced tumor stages for some malignant diseases. METHODS From January 1994 to December 2000, 693 operations for renal cell carcinoma were performed in 683 patients at our institution. Ten patients underwent surgery twice for bilateral tumors. Of the 683 patients, 417 were men and 266 women. The mean age at surgery was 62.2 years, and the mean tumor diameter was 5.2 cm. Seventy-eight percent of the patients were asymptomatic at tumor diagnosis. The following parameters were evaluated with regard to a possible correlation to tumor stage and/or tumor diameter: BMI, presence of symptoms, age, sex, hemoglobin, lactate dehydrogenase, erythrocyte sedimentation rate, serum cholesterol, and triglycerides. For statistical analysis, the Spearman rank correlation test was used. RESULTS The mean BMI was 26.8 +/- 4.4 (range 16.9 to 44.3). Statistical analysis showed a significant positive correlation between advanced T stage and the presence of symptoms (P <0.0001), erythrocyte sedimentation rate (P <0.0001), lactate dehydrogenase (P = 0.0015), and age (P = 0.046), and an inverse correlation with hemoglobin (P <0.0001) and serum cholesterol (P <0.0001). For all other investigated parameters, including BMI, no significant correlation could be proved. CONCLUSIONS Our data indicate that obese patients are not at greater risk of advanced tumor stages of renal cell carcinoma at the time of diagnosis compared with a population of normal weight.

Pancreatic metastases from renal cell carcinoma mimicking insulinomas

was notable; despite this, no pathological levels of insulin Case report and C-peptide were detectable. We omitted preoperative CT-guided needle biopsy because Whipple’s triad and the A 60-year-old man presented with RCC of the left kidney and was treated successfully by a transperitoneal nephfindings on CT supported the diagnosis of an insulinoma, because surgery is the treatment of choice for any rectomy in 1989. The histopathological examination revealed a small (2 cm in the greatest dimension) well malignancy of exocrine and endocrine pancreatic tissue, diCerentiated, clear-cell type RCC with microscopic vein involvement. The tumour was resected radically; furthermore, no regional lymph nodes or distant metastases were found. Over a follow-up of 8 years there was no evidence of local recurrence or metastatic disease. The patient began to experience unpredictable episodes of hunger associated with sweating and dizziness in October 1997. During these episodes his blood glucose levels were decreased by up to 300 mg/L. Ultrasonography showed two hypoechoic lesions in the pancreas and subsequent CT of the abdomen showed two hypervascularized well-circumscribed tumours in the body (1.5 cm) and in the tail (2.3 cm) of the pancreas (Fig. 1). However, insulin and C-peptide levels were in the normal range. In January 1998 the patient was admitted to the Department of Surgery. A distal pancreatectomy with splenectomy, combined with a tumour enucleation, was performed after intraoperative ultrasonography. An accurate tumour classification from the intraoperative frozen section was not possible, but the surgical margins were free of tumour. The definitive histopathological specimens revealed two metastases of a clear-cell type RCC (Fig. 2); near these lesions some islet cells showed a moderate hyperplasia. The postoperative course was uneventful. During a 4-month follow-up the patient had no hypoglycaemic attacks and his blood glucose levels remained within the normal range.