Julia Straub

Ureterorenoscopic biopsy and urinary cytology according to the 2004 WHO classification underestimate tumor grading in upper urinary tract urothelial carcinoma

OBJECTIVES To determine accuracy of upper tract cytology and ureteroscopic biopsy according to the 2004 World Health Organization (WHO) classification in predicting the correct tumor grade in patients with urothelial cancer of the upper urinary tract (UUT-UC). METHODS Pathology reports of 77 nephroureterectomy specimens were retrospectively analyzed for tumor grade and compared with preoperatively gained cytology and ureteroscopic biopsy results. For analysis, the 2004 WHO classification was used. RESULTS Overall sensitivity of cytology and biopsy in diagnosis of UUT-UC was 64% and 74%, respectively. Accuracy of cytology and biopsy in predicting high grade cancer was 53% and 58%, respectively. Combination of cytology and biopsy could improve sensitivity (84%) and accuracy (68%), but even for this combination, 15% of high grade tumors were misinterpreted as low grade cancer. CONCLUSION Our results show only limited accuracy for preoperative cytology and ureterorenoscopically performed biopsies in the prediction of the correct tumor grading of an UUT-UC. Therefore, we suggest the use of additional diagnostic procedures before the decision for definitive surgical treatment in patients with UUT-UC is made.

Urinary Cytology in Era of Fluorescence Endoscopy: Redefining the Role of an Established Method With a New Reference Standard

OBJECTIVES To assess whether the use of fluorescence endoscopy (FE) decreases the clinical value of urinary cytology compared with the use of white light endoscopy (WLE). METHODS The endoscopic, cytologic, and histologic findings of patients who had undergone transurethral resection of the bladder with or without FE were reviewed. The number and characteristics of the tumors that had been overlooked by WLE or FE but detected by cytology were analyzed. An assessment of whether the sensitivity and specificity of urinary cytology changed according to the use of FE or WLE was conducted. RESULTS The data from 1705 patients were included. Histologic findings were obtained from 238 patients using WLE and from 1467 patients using FE. Histologically confirmed malignancy was found in 641 patients, and the disease of 1064 was classified as benign. FE was superior to WLE in sensitivity in the detection of bladder cancer (94.3% vs 86.3%, P <.05). Cytology detected 53 of 88 tumors that were not detected by WLE (47 high-grade tumors); 31 tumors were overlooked by FE, of which 20 were detected by cytology (12 were high-grade tumors). The sensitivity and specificity of cytology was 66.0% and 78.4%, respectively. The specificity of cytology using WLE and FE was 75% and 79.1% (P >.05) and the sensitivity was 61.4% and 67.4% (P >.05), respectively. CONCLUSIONS Although FE demonstrated a great sensitivity, cytology still has a role even when using FE, because a small group of patients with high-grade tumors were detected by urinary cytology only.

Individual Learning Curve Reduces the Clinical Value of Urinary Cytology

UNLABELLED The aim of the study was to define the learning curve of a single cytologist as a limitation of urinary cytology. A total of 1034 cytologic and histologic findings of patients undergoing transurethral resection of the bladder for suspicion of bladder cancer were reviewed, and cytologic evaluations of a single cytologist from the beginning of his learning period were compared with the results of a cytologist at a national reference center. Our results showed that the individual learning curve has a significant impact on the quality of urine cytology. BACKGROUND To define the learning curve of a single cytologist as a limitation of urinary cytology and to compare his results with a reference center for urinary cytology. PATIENTS AND METHODS Cytologic and histologic findings of patients undergoing transurethral resection of the bladder for suspicion of bladder cancer were reviewed. Cytologic evaluations from a single local cytologist during his learning period and of a cytologist of a national reference center were compared. Changes of sensitivity and specificity of cytology from the local cytologist over the time period were assessed. Differences were estimated by using kappa statistics. RESULTS The local cytologist evaluated 1034 cytologic findings. Sensitivity and specificity of cytology estimated by the local cytologist were 86% and 66% at the beginning of the learning period, but 68% and 84% at the end of it (P ≤ .05). In high-grade carcinomas, sensitivity did not decrease over the years (P > .05). In contrast, the sensitivity in the diagnosis of low-grade tumors decreased from 86% to 56% (P ≤ .05). The reference center estimated a constant sensitivity and specificity of 59% and 97%, respectively. Agreement of findings between local and national cytologists increased significantly over the learning period (P < .05). CONCLUSION The individual learning curve has a significant impact on the quality of urinary cytology. Both specificity of cytology and sensitivity for low-grade tumors changed significantly when done by a local cytologist at the beginning of learning period. These findings emphasize the impact of the individual learning curve on the clinical value of urinary cytology in diagnosis of bladder cancer.

Influence of clinical information on the interpretation of urinary cytology in bladder cancer: how suggestible is a cytologist?

Study Type – Diagnosis (exploratory cohort)
Level of Evidence 2b

Harnwegsinfekte bei Kindern

Purpose of review To gain new insights into the epidemiology, imaging and conservative management of urinary tract infections based on the peer-reviewed literature of the last year. Recent findings It has been estimated that 3% of prepubertal girls and 1% of prepubertal boys are diagnosed with urinary tract infections. Breastfeeding has been shown to offer significant protection against urinary tract infection in infants. Any young child with an acute pyelonephritis should be evaluated by dimercaptosuccinic acid renal scan to confirm or rule out renal scarring. The voiding cystourethrogram can be performed within the first 7 days of diagnosis. Amoxicillin, trimethoprim-sulfamethoxazole and cephalosporin are the first-line antibiotics to treat children with uncomplicated urinary tract infection. Summary The incidence of urinary tract infections during infancy and childhood is high and influenced by the age and sex of the patient. Voiding cystourethrogram and dimercaptosuccinic acid renal scan are required for imaging. Short-course treatment is sufficient for children with acute uncomplicated lower urinary tract infections.

[Vesico-ureteral reflux: Diagnosis and treatment recommendations].

BACKGROUND Vesico-ureteral reflux (VUR) is one of the most common urologic diseases in childhood. About every third child that presents with a urinary tract infection (UTI) has urinary reflux to the ureter or kidney. Demonstration of a backflow of urine into the ureters or kidneys proves vesicoureteral reflux. In unclear cases, a positioned instillation of contrast agent (PIC) cystogram might be performed and is able to prove vesico-ureteral reflux. OBJECTIVES Since low-grade VUR has a high probability of maturation and self-limitation, infants with VUR should be given prophylactic antibiotics during their first year of life, reevaluating the status of VUR after 12 months. The aim of any treatment is to prevent renal damage. THERAPY The individual risk of renal scarring is decisive for the choice of adequate therapy. This risk is mainly dependent on reflux grade, age, and gender of the child as well as parental therapy adherence. In principle, therapeutic options include conservative as well as endoscopic or open surgical antireflux therapies. CONCLUSION Decisions on treatment should be made individually with parents taking into account all the findings available.

Management of hypospadias

Das optimale Management der Hypospadie wird nach wie vor kontrovers diskutiert: Es gibt unterschiedliche Auffassungen bezüglich Operationsbedürftigkeit, Operationszeitpunkt, Wahl des Operationsverfahrens sowie der perioperativen Betreuung. In diesem Artikel soll versucht werden, die hieraus resultierende Unsicherheit im optimalen Management der Hypospadie mindern.

Management der Hypospadie

Das optimale Management der Hypospadie wird nach wie vor kontrovers diskutiert: Es gibt unterschiedliche Auffassungen bezüglich Operationsbedürftigkeit, Operationszeitpunkt, Wahl des Operationsverfahrens sowie der perioperativen Betreuung. In diesem Artikel soll versucht werden, die hieraus resultierende Unsicherheit im optimalen Management der Hypospadie mindern.

Imaging in pediatric urology

ZusammenfassungHintergrundJahrelang waren Sonographie und Ausscheidungsurogramnn (AUG) die wichtigsten Untersuchungen zur Beurteilung des kindlichen Harntraktes. Beide Methoden haben Vor- und Nachteile: Eine Ultraschalluntersuchung erlaubt uns zwar eine optimale Visualisierung normaler Nieren sowie eine Beurteilung des Nierenbeckenkelchsystems. Für den Nachweis bzw. Ausschluss von Parenchymnarben ist diese Methode jedoch deutlich schlechter geeignet. Über die Nierenfunktion liefert sie gar keine Information.MethodenMithilfe eines AUG kann die Ausscheidung und dadurch indirekt auch die Funktion der Nieren beurteilt werden. Da diese Untersuchung jedoch eine Strahlenbelastung mit sich bringt und eine Kontrastmittelgabe erfordert, sollte sie im Kindesalter vermieden werden. Die Computertomographie ist zwar eine hervorragende Untersuchung, die fast alle kinderurologischen Fragen bzw. Krankheiten beantworten bzw. diagnostizieren kann, sie stellt aber auch die größte Strahlenbelastung für das untersuchte Kind dar. Aus diesem Grund nimmt die Magnetresonanztomographie einen immer wichtigeren Platz in der Uroradiologie ein. Zunächst wurden bei Kindern nur die T2-Sequenzen zur Visualisierung der ableitenden Harnwege angewendet.SchlussfolgerungDie aktuellen technischen Entwicklungen sowie die Anwendung von dem Kontrastmittel Gadolinium und dem Antidiuretikum Furosemid erlauben nun eine „All-in-one-Evaluation“ (Nierenparenchym und ableitende Harnwege).AbstractBackgroundFor many years, sonography and the intravenous pyelogram (IVP) were the most important examination methods for the evaluation of the urinary tract in children. Both methods have their pros and cons: sonography provides ideal visualization of normal kidneys and the evaluation of the pelvicalyceal system. For detection or exclusion of renal scarring, however, this method is not well suited. It provides no information regarding kidney function.MethodsWith an IVP, it is possible to evaluate urinary excretion and, thus, indirectly assess kidney function. As this examination method involves radiation exposure and the necessity of a contrast agent, it should be avoided in the examination of children. The CT is an excellent examination method that can diagnose nearly all urological diseases in children or answer urological questions; however, a CT scan applies the highest radiation dose of all discussed methods. For this reason, examination via MRI is of increasing importance in uroradiology. Initially only the T2 sequences for the visualization of the urinary tract in children were applied.ConclusionThe current technical developments as well as the use of the contrast agent gadolinium and the antidiuretic agent furosemide allow an all-in-one evaluation of the kidneys and urinary tract.BACKGROUND For many years, sonography and the intravenous pyelogram (IVP) were the most important examination methods for the evaluation of the urinary tract in children. Both methods have their pros and cons: sonography provides ideal visualization of normal kidneys and the evaluation of the pelvicalyceal system. For detection or exclusion of renal scarring, however, this method is not well suited. It provides no information regarding kidney function. METHODS With an IVP, it is possible to evaluate urinary excretion and, thus, indirectly assess kidney function. As this examination method involves radiation exposure and the necessity of a contrast agent, it should be avoided in the examination of children. The CT is an excellent examination method that can diagnose nearly all urological diseases in children or answer urological questions; however, a CT scan applies the highest radiation dose of all discussed methods. For this reason, examination via MRI is of increasing importance in uroradiology. Initially only the T2 sequences for the visualization of the urinary tract in children were applied. CONCLUSION The current technical developments as well as the use of the contrast agent gadolinium and the antidiuretic agent furosemide allow an all-in-one evaluation of the kidneys and urinary tract.

Ambulantes Operieren im Kindesalter@@@Pediatric outpatient surgery

ZusammenfassungHintergrundDie Zahl der ambulanten Operationen ist in den vergangenen Jahren bei Routineeingriffen gerade im Erwachsenenalter stetig gestiegen. Für viele ist es mittlerweile selbstverständlich geworden, dass Eingriffe wie z. B. eine Arthroskopie etc. ambulant durchgeführt werden. Auch in der Erwachsenenurologie sind ambulante Eingriffe wie die Vasektomie, die Hydrozelenresektion etc. inzwischen fest etabliert. Für Erwachsene stellt ein derartiger ambulanter Eingriff in der Regel eine recht gut kalkulierbare Situation dar, da sich die Patienten doch recht genau vorstellen können was auf sie zukommen wird. Bei ambulanten Operationen im Kindesalter sieht das manchmal jedoch ganz anders aus. Hier reagieren Eltern oftmals sehr besorgt und mit großer Unsicherheit auf die sich stellende Situation, da das Bevorstehende für sie viel schwerer abzuschätzen ist und sie in diesem Fall nicht für die eigene Person, sondern für das Wohl eines Kindes zu entscheiden haben.DiskussionLeider stehen den Eltern oftmals nur unzureichende Informationsquellen in der Vorbereitung für einen operativen Eingriff zur Verfügung, weshalb es eine besondere Aufgabe für alle Beteiligten (Urologen, Anästhesisten, Pflegepersonal, Telefonpersonal etc.) darstellt, hier entsprechend ausführliche und elterngerechte Angaben machen zu können.SchlussfolgerungDieser Beitrag soll verschiedene Ansatzpunkte für eine optimierte Vorbereitung und Versorgung von Kindern und Eltern im Rahmen von ambulanten kinderurologischen Operationen aufzeigen.AbstractBackgroundThe number of outpatient surgeries for routine surgical interventions continues to increase, especially in adults. For many patients, there is no doubt that interventions like arthroscopy will be performed on an outpatient basis. Regarding urologic surgeries in adults (e.g., vasectomy, hydrecelectomy), outpatient treatment is well established. For adults such a procedure represents a well-calculable situation in most cases, as the patient can quite accurately imagine the events that will follow. In terms of pediatric outpatient surgery, the scenario is sometimes quite different. Parents are more anxious and uncertain because they must decide for the well-being of their children and they often do not exactly know what will happen during the procedure. In addition, they do not have to decide for themselves but for their children.DiscussionUnfortunately, parents often lack information prior to surgery. Therefore, all persons involved in the treatment of children (e.g., urologists, anesthesiologists, nurses) must be trained and educated in giving adequate and appropriate information especially for parents.ConclusionThe purpose of this article is to provide different starting points for an optimized preparation and care of children and parents concerning outpatient surgery in pediatric urology.BACKGROUND The number of outpatient surgeries for routine surgical interventions continues to increase, especially in adults. For many patients, there is no doubt that interventions like arthroscopy will be performed on an outpatient basis. Regarding urologic surgeries in adults (e.g., vasectomy, hydrecelectomy), outpatient treatment is well established. For adults such a procedure represents a well-calculable situation in most cases, as the patient can quite accurately imagine the events that will follow. In terms of pediatric outpatient surgery, the scenario is sometimes quite different. Parents are more anxious and uncertain because they must decide for the well-being of their children and they often do not exactly know what will happen during the procedure. In addition, they do not have to decide for themselves but for their children. DISCUSSION Unfortunately, parents often lack information prior to surgery. Therefore, all persons involved in the treatment of children (e.g., urologists, anesthesiologists, nurses) must be trained and educated in giving adequate and appropriate information especially for parents. CONCLUSION The purpose of this article is to provide different starting points for an optimized preparation and care of children and parents concerning outpatient surgery in pediatric urology.