Pilar Laguna

European Consensus Conference on Diagnosis and Treatment of Germ Cell Cancer: A Report of the Second Meeting of the European Germ Cell Cancer Consensus group (EGCCCG): Part I

OBJECTIVES The first consensus report presented by the European Germ Cell Cancer Consensus Group (EGCCCG) in the year 2004 has found widespread approval by many colleagues throughout the world. In November 2006, the group met a second time under the auspices of the Department of Urology of the Amsterdam Medical Center, Amsterdam, The Netherlands. METHODS Medical oncologists, urological surgeons, radiation oncologists as well as pathologists from several European countries reviewed and discussed the data that had emerged since the 2002 conference, and incorporated the new data into updated and revised guidelines. As for the first meeting, the methodology of evidence-based medicine (EBM) was applied. The results of the discussion were compiled by the writing committee. All participants have agreed to this final update. RESULTS The first part of the consensus paper describes the clinical presentation of the primary tumor, its treatment, the importance and treatment of testicular intraepithelial neoplasia (TIN), histological classification, staging and prognostic factors, and treatment of stage I seminoma and non-seminoma. CONCLUSIONS Whereas the vast majority of the recommendations made in 2004 remain valid 3 yr later, refinements in the treatment of early- and advanced-stage testicular cancer have emerged from clinical trials. Despite technical improvements, expert clinical skills will continue to be one of the major determinants for the prognosis of patients with germ cell cancer. In addition, the particular needs of testicular cancer survivors have been acknowledged.

Follow-up of renal masses after cryosurgery using computed tomography; enhancement patterns and cryolesion size

To describe the characteristics of cryolesions as seen on computed tomography (CT), for size and enhancement patterns, and to assess correlations between these imaging findings and histopathological diagnosis, as in renal cryosurgery the tumour is ablated in situ and the follow‐up is mainly based on imaging.

Keratin expression profiling of transitional epithelium in the painful bladder syndrome/interstitial cystitis.

Painful bladder syndrome/interstitial cystitis (PBS/IC) is a severely debilitating condition. Its cause is poorly understood; therapy is symptomatic and often unsuccessful. To study urothelial involvement, we characterized the keratin phenotype of bladder urothelium in 18 patients with PBS/IC using a panel of 11 keratin antibodies recognizing simple keratins found in columnar epithelia (keratins 7, 8, 18, and 20) and keratins associated with basal cell compartments of squamous epithelia (keratins 5, 13, 14, and 17). We also tested 2 antibodies recognizing more than 1 keratin also directed against basal cell compartments of squamous epithelia (D5/16 B4 and 34betaE12). Bladder urothelium in PBS/IC showed distinct differences in the profiles of keratins 7, 8, 14, 17, 18, and 20 compared with literature reports for normal bladder urothelium. These were characterized by a shift from the normal bladder urothelial keratin phenotype to a more squamous keratin profile, despite the lack of morphologic evidence of squamous epithelial differentiation and a loss of compartmentalization of keratin expression. The severity of these changes varied between biopsy specimens. Whether these changes are primary or secondary to another underlying condition remains to be determined.

Clinical, Pathologic, and Functional Outcomes After Nephron-Sparing Surgery in Patients with a Solitary Kidney: A Multicenter Experience

BACKGROUND AND PURPOSE Surgical management of a renal neoplasm in a solitary kidney is a balance between oncologic control and preservation of renal function. We analyzed patients with a renal mass in a solitary kidney undergoing nephron-sparing procedures to determine perioperative, oncologic, and renal functional outcomes. PATIENTS AND METHODS A multicenter study was performed from 12 institutions. All patients with a functional or anatomic solitary kidney who underwent nephron-sparing surgery for one or more renal masses were included. Tumor size, complications, and recurrence rates were recorded. Renal function was assessed with serum creatinine level and estimated glomerular filtration rate. RESULTS Ninety-eight patients underwent 105 ablations, and 100 patients underwent partial nephrectomy (PN). Preoperative estimated glomerular filtration rate (eGFR) was similar between the groups. Tumors managed with PN were significantly larger than those managed with ablation (P<0.001). Ablations were associated with a lower overall complication rate (9.5% vs 24%, P=0.01) and higher local recurrence rate (6.7% vs 3%, P=0.04). Eighty-four patients had a preoperative eGFR ≥60 mL/min/1.73 m(2). Among these patients, 19 (23%) fell below this threshold after 3 months and 15 (18%) at 12 months. Postoperatively, there was no significant difference in eGFR between the groups. CONCLUSIONS Extirpation and ablation are both reasonable options for treatment. Ablation is more minimally invasive, albeit with higher recurrence rates compared with PN. Postoperative renal function is similar in both groups and is not affected by surgical approach.

Changing patterns of keratin expression could be associated with functional maturation of the developing human bladder.

PURPOSE We investigate the keratin phenotype of human transitional epithelium at various gestational ages and whether keratin composition of transitional epithelium is related to bladder function and morphology. MATERIALS AND METHODS Consecutive sections from formalin fixed paraffin embedded blocks of autopsy bladder tissue from 21 male and 5 female fetuses, gestational age 12 to 40 weeks and 7 infants 2 days to 19 months old were cut and stained with antibodies recognizing basal cell keratins 5, 14 and 17, intermediate squamous cell keratin 13 and columnar cell keratins 7, 8, 18 and 20. RESULTS With gestational age there were distinct changes in expression of keratins recognizing columnar cells, consisting of focal loss of keratin 7 in transitional epithelium, restriction of keratin 20 expression to umbrella cells and expression of keratin 18 throughout the full thickness of transitional epithelium. Basal cell keratin 5 was found above the basal cell layer while keratins 14 and 17 were not found. Squamous cell keratin 13 was found throughout the full thickness of the urothelium. CONCLUSIONS The changes with gestational age in expression of some keratins may be related to the development of the reservoir function of the bladder. The impermeability of transitional epithelium, particularly during early fetal development, is possibly a function of umbrella and intermediate transitional cells.

A Plea for Centralized Care for Ureteroscopy: Results from a Comparative Study Under Different Conditions Within the Same Center

PURPOSE We stratified factors that affect treatment morbidity, compared the outcomes of ureteroscopy procedures from a single department under different conditions, and provided evidence of treatment benefits when ureteroscopy is performed in an expert setting. PATIENTS AND METHODS Since the department became a dedicated endourologic center in 2002, we grouped all ureteroscopy procedures into those performed before 2002 (group A) and after 2002 (group B). The modified Clavien classification was used to score morbidity. Independent variables with an influence on postoperative outcomes were studied, including operative time, intraoperative and postoperative complications, and hospitalization time. RESULTS Of the 248 ureteroscopy procedures performed, 62 comprised group A and 186 comprised group B. Statistical preoperative differences were in the American Society of Anesthesiologists score, patients with diabetes mellitus, cardiovascular disease, and the use of anticoagulants; and the perioperative differences were seen in operative time, hospital stay, and the number of eventful procedures. Group A had a significantly longer operative time and a longer hospital stay compared with group B. The number of failed and eventful procedures are also higher in group A compared with group B. Stone-free rates were similar in both groups. CONCLUSIONS The dedicated setting for ureteroscopy at our center resulted in decreased operative time, more uneventful procedures, and decreased hospitalization time. The modified Clavien morbidity score is a reliable tool for more objective comparisons of morbidity after ureteroscopic stone treatment.

New Technical Improvements for TRUS in the Diagnosis of Prostate Cancer

Abstract Objectives: Together with the aging population the incidence of prostate cancer (Pca) is still increasing. For the detection of Pca the PSA blood test, digital rectal examination (DRE), and transrectal ultrasound (TRUS) are frequently used methods. TRUS has an important role in diagnosing Pca. However, the low specificity and sensitivity of conventional grayscale TRUS have made it into a volume measuring and biopsy-guiding tool. Methods: A Medline literature search on transrectal ultrasound was performed and relevant articles were reviewed. Results: New ultrasound techniques were introduced to overcome the limitations of conventional grayscale TRUS. In this paper, an overview of developments in TRUS with 3D, Doppler, contrast, intermittent, harmonic, and pulse inversion techniques along with possibilities for future development are discussed. Conclusions: The underlying principles and methods are discussed briefly and clinical results published in recent literature are presented.

Antibiotic use and the prevention and management of infectious complications in stone disease

The importance of assessing perioperative urine/stone cultures and providing appropriate antibiotic prophylaxis prior to shock wave lithotripsy (SWL) or endoscopic intervention cannot be minimized. Urinary tract infection (UTI) is the most common complication relating to stone intervention. Adequate assessment of culture data and adherence to appropriate guidelines may prevent the development of UTI and the potential for post-intervention urosepsis. This review outlines the current evidence for prophylaxis in the prevention of UTI and urosepsis, as well as the interpretation of stone culture data to provide an evidence-based approach for the judicious use of antibiotics in urologic stone practice.

ESUT expert group on laparoscopy proposes uniform terminology during radical prostatectomy: We need to speak the same language

Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Germany; Department of Urology, AMC Amsterdam, University of Amsterdam, The Netherlands; Department of Urology, Centre of Oncology, Kielce, Poland; Department of Urology, Pansadoro Foundation, Rome, Italy; Department of Urology, Luigi Sacco Hospital, University of Milan, Italy; Department of Urology, Medical School Leipzig, University of Leipzig, Germany; Department of Urology, Institute Montsouris, Paris, France; Department of Urology, University of Patras, Greece; Department of Urology, Gazi University of Ankara, Turkey; Department of Urology, Helios Kliniken Mullheim, Germany; Department of Urology, Klinikum Winterthur, Switzerland; Department of Urology, University of Basel, Switzerland; Department of Urology, Institute Jules Bordet – Universite Libre de Bruxelles, Brussels, Belgium

In Vivo Factors Influencing the Freezing Cycle During Cryoablation of Small Renal Masses

PURPOSE The aim of this study is to present a procedural analysis of the cryoablations performed in our department for small renal tumors and to try to identify clinical parameters or factors that influence the freezing rate during the procedure. PATIENTS AND METHODS We collected all data from the procedures performed in our department until August 2007. Based on the intraoperative biopsy result, we grouped the cases in two groups: renal-cell carcinoma (RCC) and benign. We calculated the freezing rate in both groups and compared them. Finally, we performed a univariate and multivariate analysis to identify clinical parameters that significantly influence the freezing rate. RESULTS A total of 70 cryoablations of small renal tumors in 67 patients were performed during this period. From these, 56 procedures met the inclusion criteria and were analyzed further. The RCC group consisted of 48 cases (39 RCC and 9 lesions with a nondiagnostic biopsy) while 8 formed the benign group. There was no difference in the freezing rate between these two groups. Preoperative creatinine levels above 120 IU, diabetes mellitus, American Society of Anesthesiologists score 3, and location of the tumor at the lower pole were found to increase the freezing rate. The only factor that significantly decreased the freezing rate was the presence of chronic obstructive pulmonary disease. The multivariate analysis showed that the location of the tumor and diabetes mellitus influence more significantly the temperature v time graph. CONCLUSIONS The freezing rate during cryotherapy of small renal tumors is significantly influenced by various clinical factors, while there are no differences in the freezing rate of those proven small malignant tumors and the small benign lesions.