M.J. Mathers

Imperative Zystektomie beim Risikopatienten

ZusammenfassungAufgrund des demographischen Wandels wird die Inzidenz von Blasenkarzinomen zunehmen. Bei muskelinvasiven Tumoren ist die radikale Zystektomie durch Fortschritte im perioperativen Management auch beim älteren Patienten indiziert. Durch die ebenfalls altersabhängige Zunahme von Komorbiditäten stellt sich die Frage nach der optimalen Harnableitung für den Risikopatienten.Das Ileumconduit stellt dazu aufgrund seiner sicheren, erprobten und risikoarmen Anwendung den Goldstandard dar. Aufgrund der Darmbeteiligung weist es jedoch relevante Komplikationsrisiken für den Risikopatienten auf. Eine noch einfachere und sichere Alternative stellt die Harnleiterhautfistel dar, die jedoch zunächst hohe Stenosierungsraten aufwies. Neuere Daten weisen allerdings darauf hin, dass vergleichbar viele Patienten ohne Harnleiterstent auskommen wie beim Ileumconduit. Auch Untersuchungen zur Lebensqualität zeigen vergleichbare Ergebnisse. Aus diesem Grund sollte die häufig zurückhaltende Einstellung gegenüber der Harnleiterhautfistel bei Risikopatienten überdacht werden.AbstractDue to the demographic trends, the incidence of bladder cancer will rise. Based on progress in perioperative management, radical cystectomy has become feasible also in elderly patients with muscle-invasive bladder cancer. Also caused by the increase of age-related comorbidities, the question arises as to the optimal urinary diversion in patients at risk.The ileal conduit is the accepted standard due to its safe, well-proven, and low-risk performance. Nevertheless, it was shown to have relevant complication rates in patients at risk, mostly because of the bowel involvement. The ureterocutaneostomy is a safer and easier alternative, which was initially shown to have a high rate of stomal stenosis. However, new data suggest that the stent-free rate is comparable to the ileal conduit. In addition, quality of life analyses show comparable results. Therefore, ureterocutaneostomy should be considered as an option for urinary diversion in patients at risk.Due to the demographic trends, the incidence of bladder cancer will rise. Based on progress in perioperative management, radical cystectomy has become feasible also in elderly patients with muscle-invasive bladder cancer. Also caused by the increase of age-related comorbidities, the question arises as to the optimal urinary diversion in patients at risk. The ileal conduit is the accepted standard due to its safe, well-proven, and low-risk performance. Nevertheless, it was shown to have relevant complication rates in patients at risk, mostly because of the bowel involvement. The ureterocutaneostomy is a safer and easier alternative, which was initially shown to have a high rate of stomal stenosis. However, new data suggest that the stent-free rate is comparable to the ileal conduit. In addition, quality of life analyses show comparable results. Therefore, ureterocutaneostomy should be considered as an option for urinary diversion in patients at risk.

Mythos oder Wahrheit

Recurrent urinary tract infections are a frequent problem in urological practice. Long-term antibiotic prophylaxis can cause resistance of some intestinal bacteria, and after therapy is stopped, infections often resume. In controlled studies, general recommendations for prophylaxis were shown to inhibit reinfection. One of these recommendations is the consumption of cranberries. A review of the literature in PubMed as well as the recently published Cochrane database systematic review confirmed that daily consumption of cranberries prevents recurrent urinary tract infections. In vitro studies have shown that binding of the P fimbriae of Escherichia coli to the uroepithelial tissue can be inhibited in the presence of proanthocyanidins, the active ingredient of cranberries. In clinical studies, the evidence is not so pronounced. Many other bacteria have fimbriae, but only a few subpopulations have P fimbriae. P fimbriae are frequent in E. coli, so this adhesion can be prevented. However, in a subanalysis of randomized and controlled studies, it was shown that women with recurrent urinary tract infections might profit from consuming cranberries.

Langzeitergebnisse der defunktionalisierten Blase nach Harnableitung

PURPOSE The remaining bladder is an almost forgotten entity. We analyzed the literature and present patient data from our institution. METHODS AND RESULTS We studied patients at our institution who received a supravesical urinary diversion without concomitant cystectomy and reviewed the relevant literature to extract pros and cons for daily practice. This retrospective study was performed in nine patients at our institution (seven women and two men) with a median age of 40 years who underwent supravesical urinary diversion without concomitant cystectomy between 1972 and 2008 for benign conditions such as incontinence, neurogenic bladder or bilateral megaureters. The median follow-up was 10 years. Additionally we performed an extensive literature search where all such patients who underwent urinary diversion without concomitant cystectomy for benign indications were identified in different retrospective analyses by various authors. RESULTS The most common complications were pyocystis (2/9), bleeding (3/9), and pain-related symptoms (1/9). Secondary carcinoma occurred in two cases. Secondary cystectomy was performed in one patient. In one patient the creation of a vesicovaginal fistula resolved the pyocystis completely. CONCLUSIONS The indication to leave the bladder in situ requires individual considerations. Due to potential complications and the progress in surgery with regards to maintaining sexual function a cystectomy should be offered to young patients. In the aging patient however a defunctionalized bladder can be discussed. The urologist should be aware of the potential complications and perform regular follow-up.

Scrotal pouch-scrotal herniation of bladder secondary to extensive bone resection due to chondrosarcoma: a simple and effective surgical treatment of urinary obstruction.

A patient developed a scrotal hernia of the bladder 6 years after resection of the pubic ramus for treatment of a chondrosarcoma. Because reconstruction of the pelvis was impossible, an alternative surgical solution was needed. A continent vesicocutaneous stoma with a full-thickness bladder tube was created. The hernia itself was not repaired, leaving the bladder and bowel loops in the scrotum. Nine years after surgery, the patient continued to perform clean intermittent catheterization. The patient had not experienced any strictures or infections. The demonstrated technique appears to be a feasible option when hernia repair is impossible.

Solitäre PSA-negative Spätmetastase eines Prostatakarzinoms in der Glans penis

Metastatische Absiedelungen im Penis selten. Dabei stammen sie in der Regel von Primarmalignomen aus dem kleinen Becken. Am haufigsten sind Metastasen von Blasen- und Prostatakarzinomen nachzuweisen. Dabei treten Penismetastasen in aller Regel nur bei einer disseminierten Metastasierung auf. Wir berichten den Fall einer singularen, PSA-negativen und asymptomatischen Metastasen eines Adenokarzinoms der Prostata in der Glans penis, die mittels lokaler Exzision behandelt werden konnte.

Imperative Zystektomie beim Risikopatienten@@@Imperative cystectomy in patients at risk: Transintestinale Harnableitung oder Harnleiterhautfistel?@@@Ileal conduit or ureterocutaneostomy?

ZusammenfassungAufgrund des demographischen Wandels wird die Inzidenz von Blasenkarzinomen zunehmen. Bei muskelinvasiven Tumoren ist die radikale Zystektomie durch Fortschritte im perioperativen Management auch beim älteren Patienten indiziert. Durch die ebenfalls altersabhängige Zunahme von Komorbiditäten stellt sich die Frage nach der optimalen Harnableitung für den Risikopatienten.Das Ileumconduit stellt dazu aufgrund seiner sicheren, erprobten und risikoarmen Anwendung den Goldstandard dar. Aufgrund der Darmbeteiligung weist es jedoch relevante Komplikationsrisiken für den Risikopatienten auf. Eine noch einfachere und sichere Alternative stellt die Harnleiterhautfistel dar, die jedoch zunächst hohe Stenosierungsraten aufwies. Neuere Daten weisen allerdings darauf hin, dass vergleichbar viele Patienten ohne Harnleiterstent auskommen wie beim Ileumconduit. Auch Untersuchungen zur Lebensqualität zeigen vergleichbare Ergebnisse. Aus diesem Grund sollte die häufig zurückhaltende Einstellung gegenüber der Harnleiterhautfistel bei Risikopatienten überdacht werden.AbstractDue to the demographic trends, the incidence of bladder cancer will rise. Based on progress in perioperative management, radical cystectomy has become feasible also in elderly patients with muscle-invasive bladder cancer. Also caused by the increase of age-related comorbidities, the question arises as to the optimal urinary diversion in patients at risk.The ileal conduit is the accepted standard due to its safe, well-proven, and low-risk performance. Nevertheless, it was shown to have relevant complication rates in patients at risk, mostly because of the bowel involvement. The ureterocutaneostomy is a safer and easier alternative, which was initially shown to have a high rate of stomal stenosis. However, new data suggest that the stent-free rate is comparable to the ileal conduit. In addition, quality of life analyses show comparable results. Therefore, ureterocutaneostomy should be considered as an option for urinary diversion in patients at risk.Due to the demographic trends, the incidence of bladder cancer will rise. Based on progress in perioperative management, radical cystectomy has become feasible also in elderly patients with muscle-invasive bladder cancer. Also caused by the increase of age-related comorbidities, the question arises as to the optimal urinary diversion in patients at risk. The ileal conduit is the accepted standard due to its safe, well-proven, and low-risk performance. Nevertheless, it was shown to have relevant complication rates in patients at risk, mostly because of the bowel involvement. The ureterocutaneostomy is a safer and easier alternative, which was initially shown to have a high rate of stomal stenosis. However, new data suggest that the stent-free rate is comparable to the ileal conduit. In addition, quality of life analyses show comparable results. Therefore, ureterocutaneostomy should be considered as an option for urinary diversion in patients at risk.

Langzeitergebnisse der defunktionalisierten Blase nach Harnableitung@@@Long-term follow-up of the defunctionalized bladder after urinary diversion

PURPOSE The remaining bladder is an almost forgotten entity. We analyzed the literature and present patient data from our institution. METHODS AND RESULTS We studied patients at our institution who received a supravesical urinary diversion without concomitant cystectomy and reviewed the relevant literature to extract pros and cons for daily practice. This retrospective study was performed in nine patients at our institution (seven women and two men) with a median age of 40 years who underwent supravesical urinary diversion without concomitant cystectomy between 1972 and 2008 for benign conditions such as incontinence, neurogenic bladder or bilateral megaureters. The median follow-up was 10 years. Additionally we performed an extensive literature search where all such patients who underwent urinary diversion without concomitant cystectomy for benign indications were identified in different retrospective analyses by various authors. RESULTS The most common complications were pyocystis (2/9), bleeding (3/9), and pain-related symptoms (1/9). Secondary carcinoma occurred in two cases. Secondary cystectomy was performed in one patient. In one patient the creation of a vesicovaginal fistula resolved the pyocystis completely. CONCLUSIONS The indication to leave the bladder in situ requires individual considerations. Due to potential complications and the progress in surgery with regards to maintaining sexual function a cystectomy should be offered to young patients. In the aging patient however a defunctionalized bladder can be discussed. The urologist should be aware of the potential complications and perform regular follow-up.

Mythos oder Wahrheit@@@Myth or truth: „Cranberry-Saft“ in der Prophylaxe und Behandlung von rezidivierenden Harnweginfektionen@@@Cranberry juice for prophylaxis and treatment of recurrent urinary tract infection

Recurrent urinary tract infections are a frequent problem in urological practice. Long-term antibiotic prophylaxis can cause resistance of some intestinal bacteria, and after therapy is stopped, infections often resume. In controlled studies, general recommendations for prophylaxis were shown to inhibit reinfection. One of these recommendations is the consumption of cranberries. A review of the literature in PubMed as well as the recently published Cochrane database systematic review confirmed that daily consumption of cranberries prevents recurrent urinary tract infections. In vitro studies have shown that binding of the P fimbriae of Escherichia coli to the uroepithelial tissue can be inhibited in the presence of proanthocyanidins, the active ingredient of cranberries. In clinical studies, the evidence is not so pronounced. Many other bacteria have fimbriae, but only a few subpopulations have P fimbriae. P fimbriae are frequent in E. coli, so this adhesion can be prevented. However, in a subanalysis of randomized and controlled studies, it was shown that women with recurrent urinary tract infections might profit from consuming cranberries.

Behandlung von spezifischen Komplikationen des lokal fortgeschrittenen Prostatakarzinoms@@@Treatment of specific complications of locally advanced prostate cancer

Despite improved screening methods and earlier detection of prostate carcinoma, the complications of locally advanced disease remain a challenge for urologists. The spectrum of possible complications includes subvesical obstruction, hydronephrosis, hematuria, pain, and local invasion of adjacent organs. Urinary diversion, palliative transurethral resection of the prostate, and endoscopic diathermy are classic procedures. Urethral stenting, laser evaporation, and selective arterial embolization are alternate approaches for treating these complex cases. Cystoprostatectomy and pelvic exenteration are ultimate options for patients with chronic pain and debilitating local symptoms.ZusammenfassungTrotz verbesserter Früherkennungsmaßnahmen bleiben die Komplikationen des fortgeschrittenen Prostatakarzinoms (PCA) eine Herausforderung für den Urologen. Das Spektrum möglicher Komplikationen umfasst die subvesikale Obstruktion, die Hydronephrose, die Hämaturie, Schmerzen und eine lokale Infiltration von Nachbarorganen. Neben klassischen Maßnahmen wie der Harnableitung durch Katheter oder Ureterstents, der palliativen transurethralen Resektion der Prostata und der endoskopischen Blutstillung stehen als Alternativen Urethrastents, Laserevaporisation und die selektive arterielle Embolisation zur Verfügung. Eine Zystoprostatektomie und die Exenteration des kleinen Beckens können bei Patienten mit unkontrollierbarer Lokalsymptomatik eine Ultima ratio darstellen.AbstractDespite improved screening methods and earlier detection of prostate carcinoma, the complications of locally advanced disease remain a challenge for urologists. The spectrum of possible complications includes subvesical obstruction, hydronephrosis, hematuria, pain, and local invasion of adjacent organs. Urinary diversion, palliative transurethral resection of the prostate, and endoscopic diathermy are classic procedures. Urethral stenting, laser evaporation, and selective arterial embolization are alternate approaches for treating these complex cases. Cystoprostatectomy and pelvic exenteration are ultimate options for patients with chronic pain and debilitating local symptoms.

Behandlung von spezifischen Komplikationen des lokal fortgeschrittenen Prostatakarzinoms

Despite improved screening methods and earlier detection of prostate carcinoma, the complications of locally advanced disease remain a challenge for urologists. The spectrum of possible complications includes subvesical obstruction, hydronephrosis, hematuria, pain, and local invasion of adjacent organs. Urinary diversion, palliative transurethral resection of the prostate, and endoscopic diathermy are classic procedures. Urethral stenting, laser evaporation, and selective arterial embolization are alternate approaches for treating these complex cases. Cystoprostatectomy and pelvic exenteration are ultimate options for patients with chronic pain and debilitating local symptoms.ZusammenfassungTrotz verbesserter Früherkennungsmaßnahmen bleiben die Komplikationen des fortgeschrittenen Prostatakarzinoms (PCA) eine Herausforderung für den Urologen. Das Spektrum möglicher Komplikationen umfasst die subvesikale Obstruktion, die Hydronephrose, die Hämaturie, Schmerzen und eine lokale Infiltration von Nachbarorganen. Neben klassischen Maßnahmen wie der Harnableitung durch Katheter oder Ureterstents, der palliativen transurethralen Resektion der Prostata und der endoskopischen Blutstillung stehen als Alternativen Urethrastents, Laserevaporisation und die selektive arterielle Embolisation zur Verfügung. Eine Zystoprostatektomie und die Exenteration des kleinen Beckens können bei Patienten mit unkontrollierbarer Lokalsymptomatik eine Ultima ratio darstellen.AbstractDespite improved screening methods and earlier detection of prostate carcinoma, the complications of locally advanced disease remain a challenge for urologists. The spectrum of possible complications includes subvesical obstruction, hydronephrosis, hematuria, pain, and local invasion of adjacent organs. Urinary diversion, palliative transurethral resection of the prostate, and endoscopic diathermy are classic procedures. Urethral stenting, laser evaporation, and selective arterial embolization are alternate approaches for treating these complex cases. Cystoprostatectomy and pelvic exenteration are ultimate options for patients with chronic pain and debilitating local symptoms.