Hans-Werner Gottfried

THE ILEAL NEOBLADDER: COMPLICATIONS AND FUNCTIONAL RESULTS IN 363 PATIENTS AFTER 11 YEARS OF FOLLOWUP

PURPOSE Since 1986 orthotopic lower urinary tract reconstruction using the ileal neobladder has been our diversion of choice in patients of both sexes undergoing cystectomy. We report on experience and functional results of the first 363 men 11 years after this procedure. MATERIALS AND METHODS Complications were assessed, tabulated, subdivided into early (3 months or less postoperatively) and late types, and further categorized with respect to relationship to neobladder construction. Continence and voiding pattern were individually evaluated via a detailed patient questionnaire. RESULTS Perioperative death occurred in 11 patients (3%). Neobladder related early and late complications occurred in 56 (15.4%) and 85 (23.4%) of the 363 patients, respectively. Neobladder related early and late abdominal reoperation rates were 0.3 and 4.4%, respectively. Perioperative neobladder unrelated early complications were observed in 122 patients (33.6%) and 44 (12.1%) required operative treatment. Late postoperative complications unrelated to the neobladder occurred in 45 patients (12.4%) and 19 required open surgical revision. Of 290 evaluable patients 96.1% void spontaneously, 3.9% perform clean intermittent catheterization in some form and 1.7% perform regular intermittent catheterization. Daytime and nighttime continence was reported as good by 95.9% and satisfactory by 95% of the patients. Unacceptable daytime continence requiring more than 1 pad per day occurred in only 4.1% of the patients and only 5% are wetting more than 1 pad a night. CONCLUSIONS The ileal neobladder produces good functional results and can be constructed with acceptable complications. Our data suggest that although it is not a complication-free procedure, we advocate its use when possible.

Surgical intervention for complications of tension-free vaginal tape procedure.

PURPOSE The tension-free vaginal tape procedure has become a state of the art operation for female stress urinary incontinence. Cases of complications requiring surgical revision are reported to be rare. We report on 6 patients with complications necessitating surgery. MATERIALS AND METHODS Six patients who previously underwent the tension-free vaginal tape procedure required surgical management of complications, including intravesical polypropylene mesh tape with incrustation and chronic urinary tract infection in 2, vaginal mucosal mesh erosion of the vaginal incision in 1 and permanent urinary retention in 3. RESULTS The intravesical tapes were resected via a suprapubic approach. In the case of disturbed wound healing the periurethral part of the tape was resected transvaginally. A patient in urinary retention underwent resection of the periurethral sling, while in the other 2 the tapes were transected transvaginally. Two patients in whom incontinence recurred were successfully treated with a repeat tension-free vaginal tape procedure during followup. CONCLUSIONS Complications of the tension-free vaginal tape procedure that require surgical intervention are rare. The surgeon must be aware that this operation may lead to an additional surgical procedure, significantly increasing morbidity.

Intensifying the saturation biopsy technique for detecting prostate cancer after previous negative biopsies: a step in the wrong direction.

To report the results using an extensive saturation biopsy in men with negative prostate biopsies but in whom there is still a clinical suspicion for carcinoma.

Classification of spatial textures in benign and cancerous glandular tissues by stereology and stochastic geometry using artificial neural networks

Stereology and stochastic geometry can be used as auxiliary tools for diagnostic purposes in tumour pathology. Whether first‐order parameters or stochastic‐geometric functions are more important for the classification of the texture of biological tissues is not known. In the present study, volume and surface area per unit reference volume, the pair correlation function and the centred quadratic contact density function of epithelium were estimated in three case series of benign and malignant lesions of glandular tissues. The information provided by the latter functions was summarized by the total absolute areas between the estimated curves and their horizontal reference lines. These areas are considered as indicators of deviation of the tissue texture from a completely uncorrelated volume process and from the Boolean model with convex grains, respectively. We used both areas and the first‐order parameters for the classification of cases using artificial neural networks (ANNs). Learning vector quantization and multilayer feedforward networks with backpropagation were applied as neural paradigms. Applications included distinction between mastopathy and mammary cancer (40 cases), between benign prostatic hyperplasia and prostatic cancer (70 cases) and between chronic pancreatitis and pancreatic cancer (60 cases). The same data sets were also classified with linear discriminant analysis. The stereological estimates in combination with ANNs or discriminant analysis provided high accuracy in the classification of individual cases. The question of which category of estimator is the most informative cannot be answered globally, but must be explored empirically for each specific data set. Using learning vector quantization, better results could often be obtained than by multilayer feedforward networks with backpropagation.

PREPUBERTAL HIGH FLOW PRIAPISM: INCIDENCE, DIAGNOSIS AND TREATMENT

PURPOSE We reviewed the literature of the last 40 years and report our experience with treating high flow priapism with fistula embolization in prepubertal boys. MATERIALS AND METHODS Two boys had blunt perineal trauma and 1 had penile trauma (ages 6, 6 and 10 years). Painless priapism developed within 24 hours and lasted for 4 to 7 days before the patients presented to the hospital. Primary diagnosis was made on color Doppler ultrasound. When high flow priapism was diagnosed angiography of the internal iliac artery and embolization of the arteriocavernosal fistula were performed. Mean followup was 26 months. RESULTS Color Doppler ultrasound revealed bilateral arteriocavernosal fistulas in 2 boys and a unilateral fistula in 1. Angiography showed fistulas of the branches of the internal pudendal artery in 2 patients and fistulas of the bulbourethral artery in 1. Microcoils were used in the bulbourethral artery and a gelatin sponge was used in other penile arteries. Complete detumescence with restored erectile function was achieved in all cases. CONCLUSIONS High flow priapism in children can be diagnosed easily by typical clinical features combined with color Doppler ultrasound. In children with posttraumatic priapism embolization of the arteriocavernosal fistula is superior to surgical or medical procedures and should be the first line therapy. Embolization using microcoils for bulbourethral arteries and a gelatin sponge for other penile arteries has proved to be safe and successful therapy.

Genetic changes in stage pT2N0 prostate cancer studied by comparative genomic hybridization.

Objective To identify chromosomal regions important for progression in clinically organ‐confined prostate cancer, as the genetic changes underlying the development and progression of prostate cancer are poorly understood.

Chromosomal Changes in Incidental Prostatic Carcinomas Detected by Comparative Genomic Hybridization

OBJECTIVES The genetic changes underlying the development and progression of prostate cancer are poorly understood. To identify chromosomal regions in incidental prostatic carcinoma (T1a and T1b) was the primary aim of this study. MATERIALS AND METHODS We used comparative genomic hybridization (CGH) to search for DNA sequence copy number changes on a series of 48 T1 prostate cancer diagnosed by transurethral resection (TURP) and by adenomectomy. Incidental prostatic carcinomas have not been studied by CGH previously. RESULTS CGH analysis indicated that 14 cases (29.2%) of incidental prostatic carcinoma showed chromosome alterations. The most frequent alterations were chromosomal losses of 8p (10.4%), 13q (6.3%), 5q (4.2%) and 18q (4.2%), and gains of 17p (10.4%), 17q (10.4%), 9q (6.3%) and 7q (4.2%). Minimal overlapping chromosomal regions of loss, indicative for the presence of tumor suppressor genes (TSGs), were mapped to 8p22 and 13q14.1-q21.3, and minimal overlapping regions of gain, indicative for the presence of oncogenes, were found at 9q34.2-qter, 17p12 and 17q24-qter. The statistical analysis displayed a significant association between chromosomal aberration detected by CGH and high Gleason score (P < 0.005) as well as between tumor categories T1a and T1b and chromosomal imbalance (P = 0.041). CONCLUSIONS Studies directed at incidental prostatic carcinomas allow discovery of chromosomal changes in small and highly malignant tumors. Our results suggest that loss or gain of DNA in these regions are important in prostate cancer. This is the first study, which documents the spectrum of chromosomal changes in incidental prostatic carcinomas.

Classification of Prostatic Carcinoma with Artificial Neural Networks Using Comparative Genomic Hybridization and Quantitative Stereological Data

Staging of prostate cancer is a mainstay of treatment decisions and prognostication. In the present study, 50 pT2N0 and 28 pT3N0 prostatic adenocarcinomas were characterized by Gleason grading, comparative genomic hybridization (CGH), and histological texture analysis based on principles of stereology and stochastic geometry. The cases were classified by learning vector quantization and support vector machines. The quality of classification was tested by cross-validation. Correct prediction of stage from primary tumor data was possible with an accuracy of 74-80% from different data sets. The accuracy of prediction was similar when the Gleason score was used as input variable, when stereological data were used, or when a combination of CGH data and stereological data was used. The results of classification by learning vector quantization were slightly better than those by support vector machines. A method is briefly sketched by which training of neural networks can be adapted to unequal sample sizes per class. Progression from pT2 to pT3 prostate cancer is correlated with complex changes of the epithelial cells in terms of volume fraction, of surface area, and of second-order stereological properties. Genetically, this progression is accompanied by a significant global increase in losses and gains of DNA, and specifically by increased numerical aberrations on chromosome arms 1q, 7p, and 8p.

Orthotopic ileal neobladder in females: impact of the urethral resection line on functional results.

Abstract: We present our functional experience with orthotopic bladder replacement in female patients dependent on the urethral resection line. Between November 1986 and July 1998 42 women underwent orthotopic urinary tract reconstruction with an ileal neobladder at our institution: 26 patients underwent radical cystectomy (RCx) with subsequent ileal anastomosis to the urethra, and 16 underwent simple cystectomy (SCx) with preservation of the bladder neck. Fourteen of 22 patients following RCx and 3 of 14 patients following bladder neck-sparing cystectomy void naturally. Clean intermittent catheterization is necessary in 8 of 22 and 11 of 14 patients, respectively. Perfect continence with no pads at 1 year postoperatively was achieved in 15 of 18 evaluable patients following RCx and 10 of 11 patients following bladder neck sparing. Incontinence requiring one or more pads is present in 3 of 18 patients and 1 of 11 patients, respectively. Subjectively satisfactory continence was achieved in 16 of 18 patients following RCx and in all patients following bladder neck-sparing surgery. Our conclusions are that radical cystectomy as well as a bladder neck-sparing cystectomy does provide satisfactory functional results in the majority of patients. However, the urethral resection line does slightly influence the rate of incontinence as well as the requirement for intermittent catheterization. RCx does translate into a lesser requirement for CIC, whereas bladder neck sparing results in slightly better continence rates.

Cluster analysis of comparative genomic hybridization (CGH) data using self-organizing maps: Application to prostate carcinomas

Comparative genomic hybridization (CGH) is a modern genetic method which enables a genome‐wide survey of chromosomal imbalances. For each chromosome region, one obtains the information whether there is a loss or gain of genetic material, or whether there is no change at that region. Usually it is not possible to evaluate all 46 chromosomes of a metaphase, therefore several (up to 20 or more) metaphases are analyzed per individual, and expressed as average. Mostly one does not study one individual alone but groups of 20–30 individuals. Therefore, large amounts of data quickly accumulate which must be put into a logical order. In this paper we present the application of a self‐organizing map (Genecluster) as a tool for cluster analysis of data from pT2N0 prostate cancer cases studied by CGH. Self‐organizing maps are artificial neural networks with the capability to form clusters on the basis of an unsupervised learning rule, i.e., in our examples it gets the CGH data as only information (no clinical data). We studied a group of 40 recent cases without follow‐up, an older group of 20 cases with follow‐up, and the data set obtained by pooling both groups. In all groups good clusterings were found in the sense that clinically similar cases were placed into the same clusters on the basis of the genetic information only. The data indicate that losses on chromosome arms 6q, 8p and 13q are all frequent in pT2N0 prostatic cancer, but the loss on 8p has probably the largest prognostic importance.