H. Riedmiller

Anatomical Basis for Pelvic Lymphadenectomy in Prostate Cancer: Results of an Autopsy Study and Implications for the Clinic

PURPOSEnPelvic lymphadenectomy remains the most reliable method to prove lymph node metastases in prostate cancer. However, evaluation of lymphadenectomy to be complete and sufficient as judged by the number of removed lymph nodes in hampered by the fact that, in contrast to other malignancies (for example breast or gastric cancer), anatomical studies investigating the regular and average number of pelvic lymph nodes are missing. We established an anatomically based standard for pelvic lymphadenectomy.nnnMATERIALS AND METHODSnStandard pelvic lymphadenectomy was performed on 30 human cadavers and 59 consecutive patients with clinically organ confined prostate cancer during radical retropubic prostatectomy. Number, size and topography of the lymph nodes were noted separately for each anatomical region of both iliac fossas.nnnRESULTSnThe mean number of lymph nodes removed in the autopsy series plus or minus standard deviation (22.7 +/- 10.2, range 8 to 56) was nearly identical to that from patients with prostate cancer (20.5 +/- 6.6, range 10 to 37) but striking interindividual differences were observed. Patients with prostate cancer demonstrated enlarged nodes regardless of whether they did or did not contain tumor. Interestingly, pelvic lymph node metastases were more common on the left side regardless of the primary tumor site.nnnCONCLUSIONSnApproximately 20 pelvic lymph nodes may serve as a guideline for a sufficient standard pelvic lymph node dissection. Lymphadenopathy in prostate cancer patients is not always a result of metastases but, rather, hyperplastic or regressive alterations. A preferential distribution of lymph node metastases along the left iliac vessels regardless of the primary tumor site in the prostate warrants further investigation.

Laparoscopic Versus Open Adrenalectomy for Adrenocortical Carcinoma: Surgical and Oncologic Outcome in 152 Patients

BACKGROUNDnThe role of laparoscopic adrenalectomy in the treatment of patients with adrenocortical carcinoma (ACC) is controversial.nnnOBJECTIVEnOur aim was to compare oncologic outcome in patients with ACC who underwent either open adrenalectomy (OA) or laparoscopic adrenalectomy (LA) for localised disease.nnnDESIGN, SETTING, AND PARTICIPANTSnWe conducted a retrospective analysis of 152 patients with stage I-III ACC with a tumour < or =10 cm registered with the German ACC Registry.nnnINTERVENTIONnPatients were stratified into two groups according to the surgical procedure (LA or OA). For comparison, we used both a matched pairs approach by selecting for each patient from the LA group (n=35) one corresponding patient from the OA group (n=117) and multivariate analysis in all 152 patients.nnnMEASUREMENTSnDisease-specific survival was chosen as the predefined primary end point. Secondary end points were recurrence-free survival, frequency of tumour capsule violation and postoperative peritoneal carcinomatosis, and incidence and reasons for conversion from LA to OA.nnnRESULTS AND LIMITATIONSnLA and OA did not differ with regard to the primary end point using either the matched pairs approach (hazard ratio [HR] for death: 0.79; 95% confidence interval [CI], 0.36-1.72; p=0.55) or multivariate analysis (HR for death: 0.98; 95% CI, 0.51-1.92; p=0.92). Similarly, adjusted recurrence-free survival was not different between LA and OA (HR: 0.91; 95% CI, 0.56-1.47; p=0.69). Frequency of tumour capsule violation and peritoneal carcinomatosis were comparable between groups. In 12 of 35 patients of the LA group, surgery was converted to open surgery with no impact on the clinical outcome.nnnCONCLUSIONSnFor localised ACC with a diameter of < or =10 cm, LA by an experienced surgeon is not inferior to OA with regard to oncologic outcome.

Expression of microRNA‐221 is progressively reduced in aggressive prostate cancer and metastasis and predicts clinical recurrence

Emerging evidence shows that microRNAs (miR) are involved in the pathogenesis of a variety of cancers, including prostate carcinoma (PCa). Little information is available regarding miR expression levels in lymph node metastasis of prostate cancer or the potential of miRs as prognostic markers in this disease. Therefore, we analyzed the global expression of miRs in benign, hyperplastic prostate tissue (BPH), primary PCa of a high risk group of PCa patients, and corresponding metastatic tissues by microarray analysis. Consistent with the proposal that some miRs are oncomirs, we found aberrant expression of several miRs, including the downregulation of miR‐221, in PCa metastasis. Downregulation of miR‐221 was negatively correlated with the expression of the proto‐oncogen c‐kit in primary carcinoma. In a large study cohort, the prostate‐specific oncomir miR‐221 was progressively downregulated in aggressive forms of PCa. Downregulation of miR‐221 was associated with clinicopathological parameters, including the Gleason score and the clinical recurrence during follow up. Kaplan–Meier estimates and Cox proportional hazard models showed that miR‐221 downregulation was linked to tumor progression and recurrence in a high risk prostate cancer cohort. Our results showed that progressive miR‐221 downregulation hallmarks metastasis and presents a novel prognostic marker in high risk PCa. This suggests that miR‐221 has potential as a diagnostic marker and therapeutic target in PCa.

Radical cystectomy : Often too late?

From 1967 to 1985, 246 cystectomies for treatment of transitional cell carcinoma of the urinary bladder were performed. Perioperative mortality decreased from 15% in the early years to 0% in 1985. Preoperative radiotherapy was not given. Patients who underwent cystectomy immediately following the diagnosis of invasive bladder carcinoma had a significantly better prognosis than those having cystectomy after recurrence of a transurethrally resected invasive carcinoma in spite of identical G and T criteria. A total of 26 patients who were cystectomized because of tumor recurrence after definitive radiotherapy (salvage cystectomy) represented the group with the worst prognosis: they had a 5-year survival rate of less than 10%. It is concluded from these results that recurrence of an infiltrating bladder tumor is an indication of poor prognosis. Early cystectomy after diagnosis of tumor infiltration can improve survival rates. Transurethral resection without adjuvant therapy cannot be regarded as reliable curative treatment of bladder cancer infiltrating the lamina propria (pT1). Modern surgical techniques of continent urinary diversion or total bladder replacement combined with sparing of the pelvic nerves (and thus preservation of potency) reinforce our view that radical cystoprostatectomy need no longer be regarded as mutilating surgery.

Continent appendix stoma : a modification of the mainz pouch technique

The submucosally embedded in situ appendix guarantees an ideal continence mechanism in patients with ileocecal urinary reservoirs. To date this modification of the Mainz pouch technique has been performed successfully in 13 patients. The appendicocutaneous stoma was placed at the lower right abdominal quadrant in 12 patients and into the umbilical funnel in 1. Urodynamic investigations of the submucosally embedded appendix showed a maximum closure pressure of more than 80 cm. water in pressure profiles. Only 1 case of stomal stenosis required reoperation.

EAU Guidelines on Vesicoureteral Reflux in Children

CONTEXTnPrimary vesicoureteral reflux (VUR) is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal of treatment, which necessitates identification of patients requiring early intervention.nnnOBJECTIVEnTo present a management approach for VUR based on early risk assessment.nnnEVIDENCE ACQUISITIONnA literature search was performed and the data reviewed. From selected papers, data were extracted and analyzed with a focus on risk stratification. The authors recognize that there are limited high-level data on which to base unequivocal recommendations, necessitating a revisiting of this topic in the years to come.nnnEVIDENCE SYNTHESISnThere is no consensus on the optimal management of VUR or on its diagnostic procedures, treatment options, or most effective timing of treatment. By defining risk factors (family history, gender, laterality, age at presentation, presenting symptoms, VUR grade, duplication, and other voiding dysfunctions), early stratification should allow identification of patients at high potential risk of renal scarring and urinary tract infections (UTIs). Imaging is the basis for diagnosis and further management. Standard imaging tests comprise renal and bladder ultrasonography, voiding cystourethrography, and nuclear renal scanning. There is a well-documented link with lower urinary tract dysfunction (LUTD); patients with LUTD and febrile UTI are likely to present with VUR. Diagnosis can be confirmed through a video urodynamic study combined with a urodynamic investigation. Early screening of the siblings and offspring of reflux patients seems indicated. Conservative therapy includes watchful waiting, intermittent or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with LUTD. The goal of the conservative approach is prevention of febrile UTI, since VUR will not damage the kidney when it is free of infection. Interventional therapies include injection of bulking agents and ureteral reimplantation. Reimplantation can be performed using a number of different surgical approaches, with a recent focus on minimally invasive techniques.nnnCONCLUSIONSnWhile it is important to avoid overtreatment, finding a balance between cases with clinically insignificant VUR and cases that require immediate intervention should be the guiding principle in the management of children presenting with VUR.

Quality of Life After Cystectomy and Urinary Diversion: Results of a Retrospective Interdisciplinary Study

PURPOSEnNow that creation of continent urinary reservoirs has become a standardized and clinically well established surgical technique with known morbidity and mortality rates, we reassessed the psychological and social aspects of this treatment compared with wet urostomy.nnnMATERIALS AND METHODSnWe developed a questionnaire (102 items) addressing general aspects of quality of life, disease related social support, coping strategies and stoma related issues. It was mailed to 600 patients with ileal conduits and 130 with continent reservoirs. Final analysis was restricted to 192 patients operated upon within the last 5 years (mean followup 2.7 years).nnnRESULTSnThe resulting groups were matched and paralleled regarding most treatment related and sociodemographic data. Final analysis did not reveal differences between the groups in disease related social support, coping strategies or quality of life when expressed as a total score. We found statistically significant superiority of continent reservoirs regarding all stoma related items, patient global self-assessment of their quality of life (single item, p < 0.005), physical strength, mental capacity, leisure time activities and social competence (p < 0.05).nnnCONCLUSIONSnContinent diversion is clearly advantageous with respect to all items directly related to the stoma. The significant superiority of continent diversion in patient global self-assessment of their quality of life reflects the highly subjective dimension of the concept. Superiority in self-ratings of physical strength, mental capacity, leisure time activities and social competence could be interpreted as indicators of enhanced vitality in those patients, thus, supporting our understanding that women and men who actively participate in life have a special benefit from continent reservoirs.

Biodistribution and Radiation Dosimetry for a Probe Targeting Prostate-Specific Membrane Antigen for Imaging and Therapy

Prostate-specific membrane antigen (PSMA) is a promising target for diagnosis and treatment of prostate cancer. EuK-Subkff-68Ga-DOTAGA (68Ga-PSMA Imaging & Therapy [PSMA I&T]) is a recently introduced PET tracer for imaging PSMA expression in vivo. Whole-body distribution and radiation dosimetry of this new probe were evaluated. Methods: Five patients with a history of prostate cancer were injected intravenously with 91–148 MBq of 68Ga-PSMA I&T (mean ± SD, 128 ± 23 MBq). After an initial series of rapid whole-body scans, 3 static whole-body scans were acquired at 1, 2, and 4 h after tracer injection. Time-dependent changes of the injected activity per organ were determined. Mean organ-absorbed doses and effective doses were calculated using OLINDA/EXM. Results: Injection of 150 MBq of 68Ga-PSMA I&T resulted in an effective dose of 3.0 mSv. The kidneys were the critical organ (33 mGy), followed by the urinary bladder wall and spleen (10 mGy each), salivary glands (9 mGy each), and liver (7 mGy). Conclusion: 68Ga-PSMA I&T exhibits a favorable dosimetry, delivering organ doses that are comparable to (kidneys) or lower than those delivered by 18F-FDG.

EAU guidelines on paediatric urology.

Treatment Therapy of phimosis in children is dependent on parents’ preferences and can be plastic or radical circumcision after completion of the second year of life. In case of complicating findings, such as recurrent urinary tract infections (UTIs) or ballooning of the foreskin during micturition, circumcision should be performed without delay regardless of the patient’s age. Routine neonatal circumcision to prevent penile carcinoma is not indicated. Contraindications of the operation are acute local infection and congenital anomalies of the penis, particularly hypospadias, as the foreskin may be required for plastic correction. As a conservative treatment option, a corticoid ointment (0.05–0.1%) can be administered twice a day over a period of 20–30 days. This treatment is not indicated in babies and children still wearing diapers, but may be considered around the third year of life. Therapy of paraphimosis consists of manual compression of the oedeomatous tissue with the subsequent attempt to retract the tightened foreskin over the glans penis. If this manoeuvre fails, a dorsal incision of the constrictive ring is required. Depending on the local findings, a circumcision is carried out immediately or can be performed in a second session.

Ileocecal vaginal construction

In 10 patients, six with previously falled vaginal reconstruction of Mayer-Rokitansky syndrome, two with male pseudohermaphrodltism, one with a history of Wertheim-Meigs operation followed by irradiation of the true pelvis, and one with vaginectomy caused by trauma, a neovagina was created out of cecal or ileocecal segments. Advantages of this technique are the excellent blood supply to the ileocecal region and the long vascular pedicle. The supplemental application of terminal Ileum for prolongation of the cecal vaginoplasty allows for tensionless anastomosis between the neovagina and the vulva, even in patients with difficult anatomic conditions. A detailed description of the operative technique and Indications for ileocecal and cecal vaginoplasty are presented, and the techniques in current use for vaginal replacement are reviewed and discussed.