M. Schostak

Optimizing local anesthesia during 10-core biopsy of the prostate

OBJECTIVES To examine, in a prospective, randomized study, the effect of different anesthetic techniques versus no anesthesia in a 10-core prostate biopsy. Reports thus far have shown a high variability in assessing the pain intensity of prostate biopsies and the effectiveness of anesthesia. METHODS Ultrasound-guided 10-core prostate biopsy was performed. Patients were prospectively randomized into four groups: no local anesthesia (group 1); anesthetic block of the prostatic plexus (group 2); local anesthesia onto the capsula of the apex (group 3); and a combination of the anesthesia used for groups 2 and 3 (group 4). The degree of pain was recorded using the visual analog scale/numeric analog scale (VAS/NAS) score. RESULTS The study included 187 patients. Results were assessed in 170 patients: 44 in group 1, 44 in group 2, 40 in group 3, and 42 in group 4. In group 1 (no anesthesia), 2 (4.5%) of 44 patients had no pain during biopsy (VAS/NAS = 0); the pain was mild (VAS/NAS of 1 to 4) in 38 (86.4%), moderate (VAS/NAS of 4 to 7) in 3 (6.8%), and severe (VAS/NAS of greater than 7) in 1 (2.3%) of 44 patients. The mean pain scores were 2.33 in group 1, 1.68 in group 2 (P = 0.05), 1.07 in group 3 (P <0.001), and 1.23 in group 4 (P <0.001). Pain caused by the local anesthesia itself was 0 in group 1, 1.52 in group 2 (P = 0.001), 1.05 in group 3 (P = 0.001), and 1.79 in group 4 (P = 0.001). CONCLUSIONS Local anesthesia significantly reduces pain. An injection onto the capsule at the apex was the most effective technique. It is technically easier to perform than an anesthetic block of the prostatic plexus and can be recommended.

Quantitative Detection of Human Complement Factor H-Related Protein in Transitional Cell Carcinoma of the Urinary Bladder

Objective: The purpose of this study was to assess a new quantitative urinary tumor marker for transitional cell carcinoma of the urinary bladder (TCC), human complement factor H-related protein (hCFHrp, BTA TRAKTM). Methods: Urine samples of 298 individuals (76 healthy volunteers, 118 patients with benign urologic disorders, 104 patients with histologically proven bladder cancer) were examined for the presence of hCFHrp. Samples of all patients were obtained prior to therapy. Results: In comparison to healthy volunteers, patients with TCC had significantly higher urinary levels of hCFHrp (117.60 vs. 2.05 U/ml; p < 0.001). HCFHrp levels were positively correlated with tumor grade and stage. Patients with invasive TCC had significantly higher levels of hCFHrp than patients with superficial TCC (p = 0.001). Marker levels in superficial bladder cancer at high risk of tumor progression (pT1G3) were significantly higher as compared to low and intermediate grade superficial cancers. Elevated levels of hCFHrp were also found in patients with benign urologic disorders (median: 72.65 vs. 117.60 U/ml in cancer patients). Using a cutoff of 17.1 U/ml, hCFHrp had a sensitivity of 72.1% and, due to a high rate of false-positive determinations in patients with benign urologic disorders, a total specificity of 50.5%. Conclusions: HCFHrp (BTA TRAKTM) is a sensitive test for detection of bladder cancer and for identification of patients at high risk. Due to a high rate of false-positive results in patients with benign urologic diseases, the test should not be used in an unselected population.

Evaluation of urinary bladder cancer antigen as a marker for diagnosis of transitional cell carcinoma of the urinary bladder

The purpose of the present study was to assess a new quantitative urinary tumor marker for transitional cell carcinoma of the urinary bladder (TCC), measuring fragments of cytokeratin 8 and 18 in the urine (UBC). Urine samples of 355 individuals (77 healthy volunteers, 111 patients with benign urologic disorders, 167 patients with histologically proven bladder cancer) were examined for the presence of UBC antigen. Samples of all patients were obtained prior to therapy. Compared to healthy volunteers or patients with benign urologic disease, patients with TCC had significantly higher median urinary levels of UBC antigen (0 vs. 4.18 vs. 7.46 microg/g creatinine; p<0.001, and p<0.01, respectively). UBC antigen levels were positively correlated with tumor grade and stage. Patients with invasive TCC had significantly higher levels of UBC antigen than patients with superficial TCC (p<0.001). Elevated levels of UBC antigen were also found in patients with benign urologic disorders (median: 4.18 microg/g creatinine vs. 7.46 microg/g creatinine in cancer patients). Using a cutoff of 14.06 microg/g creatinine (corresponding to 95% specificity in the group of healthy individuals), sensitivity of UBC antigen ranged between 21.6% (pTa) and 75% (pT4). Overall specificity was 76.6%. Based on our data we conclude that the UBC antigen test in its current format is not clinically useful for detection of bladder cancer.

The differentiation status of primary gonadal germ cell tumors correlates inversely with telomerase activity and the expression level of the gene encoding the catalytic subunit of telomerase

BackgroundThe activity of the ribonucleoprotein enzyme telomerase is detectable in germ, stem and tumor cells. One major component of telomerase is human telomerase reverse transcriptase (hTERT), which encodes the catalytic subunit of telomerase. Here we investigate the correlation of telomerase activity and hTERT gene expression and the differentiation status of primary testicular germ cell tumors (TGCT).MethodsTelomerase activity (TA) was detected by a quantitative telomerase PCR ELISA, and hTERT mRNA expression was quantified by online RT-PCR in 42 primary testicular germ cell tumors. The control group consisted of benign testicular biopsies from infertile patients.ResultsHigh levels of telomerase activity and hTERT expression were detected in all examined undifferentiated TGCTs and in the benign testicular tissue specimens with germ cell content. In contrast, differentiated teratomas and testicular control tissue without germ cells (Sertoli-cell-only syndrome) showed no telomerase activity and only minimal hTERT expression.ConclusionsThese findings demonstrate an inverse relationship between the level of telomerase activity and hTERT mRNA expression and the differentiation state of germ cell tumors. Quantification of telomerase activity and hTERT mRNA expression enables a new molecular-diagnostic subclassification of germ cell tumors that describes their proliferation potential and differentiation status.

Transvaginal Bone Anchors in Female Stress Urinary Incontinence: Poor Results

Objective: This study evaluates the results of a minimally invasive technique for correcting female stress urinary incontinence by transvaginal implantation of pubic bone anchors. Patients and Methods: Female stress urinary incontinence was treated by fixing a gelatin-coated Dacron sling between two miniature titanium anchors with Prolene sutures. Results: A total of 26 patients (median age 57.2 years) underwent the sling procedure. The follow-up examination was performed after 11.4 months on average. Stress incontinence showed a median improvement from grade 2 to grade 0.5 (p = 0.01), although only 16 of the 26 patients were completely continent. Urethral pressure and functional length were not significantly influenced. Impaired vaginal wound healing was seen in 14 of the 26 patients (53.8%), and 13 of them underwent revision. All patients affected (15/26, 57.7%) as well as 1 with uneventful healing showed sensory urge symptoms or detrusor instability (7/26, 26.9%). The correlation between impaired wound healing and detrusor instability was highly significant (p < 0.003). 17 of the 26 patients (65.3%) were dissatisfied or very dissatisfied with the intervention. The unfavorable results did not significantly correlate with the patients’ age, the number of previous operations, or the surgeon’s skill. Conclusion: In view of the poor vaginal wound healing and the resultant irritative symptoms, transvaginal bone anchoring with fixation of a Dacron sling must be regarded as an unsuitable technique.

Minimal-invasiver Knochenanker in der Therapie der weiblichen Stressinkontinenz Ein gutes Konzept?

ZusammenfassungDie vorliegende Untersuchung bewertet die Ergebnisse einer neuen minimal-invasiven Operationstechnik zur Korrektur der weiblichen Stressinkontinenz durch transvaginal in das Os pubis applizierte Knochenanker.Zwei Operationstechniken standen zur Verfügung: Die Zystourethropexie und die Implantation eines gelatinebeschichteten Polyethylenzügels zwischen 2 Ankern. Bei 4 von insgesamt 17 Patientinnen wurde eine Zystourethropexie durchgeführt, 13 erhielten eine Zügelplastik.Die Stressinkontinenz verbesserte sich im Mittel von Grad 2 auf 1,35 (p=0,01); 9 von 17 (53%) Patientinnen wiesen eine vaginale Heilungsstörung auf, 8 davon wurden revidiert. Es konnte keine signifikante Korrelation des ungünstigen Ergebnisses mit der Operationsmethode, dem Alter, der Zahl der Voroperationen oder dem Operateur errechnet werden.Aufgrund der überwiegend schlechten vaginalen Wundheilung und der damit häufig verbundenen irritativen Symptomatik muss die Technik der transvaginalen Knochenankerapplikation sowohl mit Zystourethropexie als auch mit einem Polyethylenzügel als ungeeignet bewertet werden.AbstractTransvaginal pubic bone anchoring represents a minimally invasive technique for cystourethropexy or urethral sling suspension. This study assesses the results of this procedure.Cystourethropexy was performed in 4 and a sling procedure in 13 of 17 patients. The stress incontinence showed a median improvement from grade 2 to 1.35 (p=0.01). Nine patients had impaired vaginal wound healing with urge symptoms. Revision was necessary in eight of them. An unfavorable outcome could not be significantly correlated with the surgical technique, the surgeon, the patients age or the number of previous operations.The technique of minimally invasive bone anchoring must be regarded as unsuitable in view of the largely poor wound healing associated with irritation symptoms.

New concept minimizes bleeding in radical retropubic prostatectomy

BACKGROUND Radical retropubic prostatectomy is an intervention known to be associated with severe bleeding. Even experienced surgeons report a blood transfusion rate of up to 20%. The perioperative concept for this intervention underwent various modifications in January 2001. This study describes the effect of these modifications on the blood loss in a retrospective analysis comparing approximately 100 operations by a single experienced surgeon before the change (group 1) with 100 operations thereafter (group 2). MATERIALS AND METHODS The new perioperative concept comprised the following points: reducing the intravenously applied volume, employing a peridural catheter (PDC), and maintaining a 25-30 degrees Trendelenburgs position. The difference in pre- and postsurgical hemoglobin (Hb) was analyzed before (group 1) and after the intervention (group 2). If transfusions were performed, this value was corrected according to the following formula: 1 ml of erythrocyte concentrate increases the patients Hb by 0.003 g/dl. RESULTS Assessment was possible in 201 of 234 cases, 110 from the first and 91 from the second group. The mean transfusion-corrected Hb difference was 5.3 g/dl in group 1 (20% transfusion rate) and 3.52 g/dl in group 2 (1.09% transfusion rate); p>0.0001. The median intravenous volume applied was 5.960 ml in group 1 and 3.490 ml in group 2 (p>0.0001). The complication rate did not differ between groups. CONCLUSION The new perioperative concept minimizes the intraoperative blood loss during radical open retropubic prostatectomy. Transfusions are only necessary in rare cases. The complication rate remains unaltered.

Neues in der operativen Inkontinenztherapie – Das hat sich nicht bewährt!

ZusammenfassungIm Rahmen des allgemeinen Aufschwungs der minimal-invasiven Chirurgie innerhalb der letzten 15 Jahre wurden auch in der Therapie der weiblichen Inkontinenz mehrere neue Methoden inauguriert. In Weiterführung der Technik der Blasenhalssuspension nach Stamey-Pereyra wurde besonders die Verwendung von Miniknochenankern propagiert. Diese zeigt gute Initialergebnisse bei geringer Komplikationsrate, jedoch nur zu 40–71% dauerhafte Kontinenz.Die von ventral durchgeführte perkutane Implantation von Miniknochenankern mit daran befestigter Suspension (“Vesica”) erzielt eine Kontinenz in 24–94%. Die Heilungsraten bei der transvaginalen Applikation von Miniknochenankern (“Intac/Infast”) reichen von 52–100%. Insbesondere bei Verwendung von synthetischen, aber auch von autologen Materialien ist mit Fremdkörperreaktionen zu rechnen. Diese sind häufig mit einer Detrusorinstabilität oder sensorischen Urge-Symptomatik verbunden.AbstractThe general advances made in minimal invasive surgery in the last 15 years has also led to the introduction of several new techniques for treating female incontinence. In the further development of bladder neck suspension according to Stamey-Pereyra, the use of miniature bone anchors received considerable support.Bladder neck suspension according to Stamey-Pereyra yields good initial results with a low complication rate but achieves permanent continence in only 40–71%. The anterior percutaneous implantation of miniature bone anchors with the attached suspension effects continence rates between 24% and 94%. Healing rates for transvaginal application of miniature bone anchors range from 52% to 100%. Reactions to foreign bodies are particularly common with synthetics but also occur with autologous materials. They are often associated with detrusor instability or sensory urge symptoms.Though these minimally invasive techniques can reduce the severity of stress incontinence, long-term healing is only achieved in about half the cases. The techniques described appear to be particularly unsuitable for treating grade III stress incontinence.The morbidity is unacceptable, especially when synthetic material is used in combination with bone anchors. Impaired vaginal wound healing often occurs in conjunction with irritative symptoms.