R. Mager

R.E.N.A.L. Score Outperforms PADUA Score, C-Index and DAP Score for Outcome Prediction of Nephron Sparing Surgery in a Selected Cohort

PURPOSE Several nephrometry scores have been proposed to predict perioperative outcomes in renal surgery. We evaluated which nephrometry score correlates best with the MIC (margin, ischemia and complications) score and quantitative perioperative outcomes in nephron sparing surgery. MATERIALS AND METHODS Data on 188 patients undergoing nephron sparing surgery were retrospectively investigated for patient, operative and tumor characteristics. Nephrometry scores, including R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, hilar tumor touching the main renal artery or vein and location relative to polar lines), PADUA (preoperative aspects and dimensions used for an anatomical), C-index (concordance index) and DAP (diameter-axial-polar), were measured on preoperative computerized tomography or magnetic resonance imaging and coded continuously and categorically. Parameters pertaining to tumor margin, ischemia and complications were recorded as binary scores and classified as MIC achievement. Operative time, estimated blood loss, warm ischemia time and hospital stay were recorded as quantitative perioperative outcomes. RESULTS The R.E.N.A.L. score correlated best with MIC and quantitative perioperative outcomes. The continuously coded R.E.N.A.L. score was predictive of MIC on univariate analysis (OR 0.75, 95% CI 0.58-0.97, p = 0.03) and it had the best predictive value on multivariate logistic regression analysis (OR 0.31, 95% CI 0.18-0.82, p = 0.03). The C-index but not the PADUA or the DAP score was predictive of MIC on univariate and multivariate logistic regression analysis. MIC achievement rates were significantly higher for low than for high complexity tumors as assessed by categorically coded R.E.N.A.L. score, C-index and DAP scores. Continuously coded R.E.N.A.L. and PADUA scores positively correlated with operative time, warm ischemia time and hospital stay. The C-index and the DAP score correlated with warm ischemia time. CONCLUSIONS Of 4 nephrometry scores the R.E.N.A.L. score correlated best with MIC achievement and quantitative perioperative outcomes of nephron sparing surgery.

The hydrodynamic basis of the vacuum cleaner effect in continuous-flow PCNL instruments: an empiric approach and mathematical model.

AbstractPurposePassive removal of stone fragments in the irrigation stream is one of the characteristics in continuous-flow PCNL instruments. So far the physical principle of this so-called vacuum cleaner effect has not been fully understood yet. The aim of the study was to empirically prove the existence of the vacuum cleaner effect and to develop a physical hypothesis and generate a mathematical model for this phenomenon. Methods In an empiric approach, common low-pressure PCNL instruments and conventional PCNL sheaths were tested using an in vitro model. Flow characteristics were visualized by coloring of irrigation fluid. Influence of irrigation pressure, sheath diameter, sheath design, nephroscope design and position of the nephroscope was assessed. Experiments were digitally recorded for further slow-motion analysis to deduce a physical model.ResultsIn each tested nephroscope design, we could observe the vacuum cleaner effect. Increase in irrigation pressure and reduction in cross section of sheath sustained the effect. Slow-motion analysis of colored flow revealed a synergism of two effects causing suction and transportation of the stone. For the first time, our model showed a flow reversal in the sheath as an integral part of the origin of the stone transportation during vacuum cleaner effect. The application of Bernoulli’s equation provided the explanation of these effects and confirmed our experimental results.ConclusionsWe widen the understanding of PCNL with a conclusive physical model, which explains fluid mechanics of the vacuum cleaner effect.

Minimally invasive versus conventional large-bore percutaneous nephrolithotomy in the treatment of large-sized renal calculi: Surgeon’s preference?

Abstract Objective: The aim of this study was to compare the efficacy and safety of minimally invasive percutaneous nephrolithotomy (MIP) and conventional percutaneous nephrolithotomy (PCNL) in the treatment of patients with large renal stone burden. MIP has proven its efficacy and safety in the management of small renal calculi. However, conventional PCNL is still considered the standard method for treatment of large renal stones in the upper urinary tract. Materials and methods: A search of two longitudinal databases in two tertiary referral centres for complex stone disease identified 133 consecutive patients who were treated by either MIP or PCNL for renal stones 20 mm or larger between January 2009 and August 2012. Clinical data and outcome measures of the two methods were compared by Student’s t test, chi-squared test or Fisher’s exact test. A p value less than 0.05 was considered statistically significant. Results: Operative time was significantly shorter and hospital stay was significantly longer in conventional PCNL compared to MIP (p = 0.002 and < 0.001, respectively). There were no significant differences in primary stone-free rate or complication rate between the two methods. Only higher graded complications (above Clavien grade II) were significantly more common in conventional PCNL (p = 0.02). Conclusion: MIP is equally effective as conventional PCNL in the treatment of large renal calculi. Both methods have a similar complication rate. The shorter operative time in PCNL may be based on the larger diameter and quicker retrieval of large fragments; the longer mean hospital stay may be caused by the handling of the nephrostomy tube. The current data suggest that the choice of the method mainly depends on the surgeon’s preference.

sE-cadherin serves as a diagnostic and predictive parameter in prostate cancer patients

BackgroundMeasurement of prostate-specific antigen (PSA) advanced the diagnostic and prognostic potential for prostate cancer (PCa). However, due to PSA’s lack of specificity, novel biomarkers are needed to improve risk assessment and ensure optimal personalized therapy. A set of protein molecules as potential biomarkers was therefore evaluated in serum of PCa patients.MethodsSerum samples from patients undergoing radical prostatectomy (RPE) for biopsy-proven PCa without neoadjuvant treatment were compared to serum samples from healthy subjects. Preliminary screening of 119 proteins in 10 PCa patients and 10 controls was carried out by the Proteome Profiler Antibody Array. Those markers showing distinct differences between patients and controls were then further evaluated by ELISA in the serum of 165 PCa patients and 19 controls. Uni- and multivariate as well as correlation analysis were performed to test the capability of these molecules to detect disease and predict pathological outcome.ResultsScreening showed that soluble (s)E-cadherin, E-selectin, MMP2, MMP9, TIMP1, TIMP2, Galectin and Clusterin warranted further evaluation. sE-Cadherin, TIMP1, Galectin and Clusterin were significantly over- and MMP9 under-expressed in PCa compared to controls. The concentration of sE-cadherin, MMP2 and Clusterin correlated negatively and that of MMP9 and TIMP1 positively with the Gleason Sum at prostatectomy. Only sE-cadherin significantly correlated with the highest Gleason pattern. Compared to serum PSA, sE-cadherin provided an independent and better matching predictive ability for discriminating PCas with an upgrade at RPE and aggressive tumors with a Gleason Sum ≥7.ConclusionssE-cadherin performed most favorably from a large panel of serum proteins in terms of diagnostic and predictive potential in curatively treatable PCa. sE-cadherin merits further investigation as a biomarker for PCa.

[Fusion imaging in urology: combination of MRI and TRUS for detection of prostate cancer].

Multiparametric magnetic resonance imaging (MRI) represents the most accurate imaging modality for prostate cancer imaging to date. Transrectal ultrasound (TRUS) is easily applied and therefore remains the gold standard for systematic prostate biopsies. However, the advantages of both modalities can be combined by image fusion. Currently, several image fusion devices are being implemented into clinical routine. First data show an increased detection rate of prostate cancer compared to systematic TRUS biopsies. At present prostatic deformation and intracorporeal movement represent technical challenges yet to be overcome. The present article gives an overview about the status of MRI-based biopsy techniques and highlights the current studies on the topic.ZusammenfassungDerzeit stellt die multiparametrische Magnetresonanztomographie (MRT) die diagnostisch genaueste Methode zur Darstellung eines Prostatakarzinoms dar. Der Goldstandard zur Prostatabiopsie ist aufgrund der einfachen Anwendung die systematische Biopsie mit dem transrektalen Ultraschall (TRUS). Durch die Kombination können die Vorteile beider Methoden genutzt werden. Mittlerweile befinden sich mehrere Bildgebungssysteme zur fusionsbildgestützten Biopsie in der Erprobung. Erste Daten zeigen höhere Karzinomdetektionsraten als bei der systematischen TRUS-Biopsie. Allerdings stellen die Verformung der Prostata und die intrakorporale Beweglichkeit Herausforderungen dar, die noch nicht abschließend gelöst sind. Der vorliegende Artikel gibt eine Übersicht über den aktuellen Stand der MRT-gestützten Biopsieverfahren und beleuchtet die aktuelle Datenlage.AbstractMultiparametric magnetic resonance imaging (MRI) represents the most accurate imaging modality for prostate cancer imaging to date. Transrectal ultrasound (TRUS) is easily applied and therefore remains the gold standard for systematic prostate biopsies. However, the advantages of both modalities can be combined by image fusion. Currently, several image fusion devices are being implemented into clinical routine. First data show an increased detection rate of prostate cancer compared to systematic TRUS biopsies. At present prostatic deformation and intracorporeal movement represent technical challenges yet to be overcome. The present article gives an overview about the status of MRI-based biopsy techniques and highlights the current studies on the topic.

„Watchful waiting“ und aktive Überwachung kleiner Nierentumoren

The incidence of small renal masses ≤4 cm is increasing due to the widespread use of cross-sectional imaging. The majority of these represent indolent forms, but the risk for developing metastases is reported in up to 6% of patients. Particularly in old and comorbid patients surgery might be harmful overtreatment. Thus, there is an increasing demand to establish oncologically safe active surveillance protocols. Radiographic or biopsy-based biological markers to appropriately designate candidates for active surveillance are currently the focus of research.ZusammenfassungDie Inzidenz kleiner Nierenzellkarzinome ≤4 cm steigt mit der ausgedehnten Nutzung von Schnittbildgebung. Die Tumoren weisen meist wenig Aggressivität auf, wobei das Risiko der Metastasierung trotzdem bis zu 6 % betragen kann. Insbesondere für alte komorbide Patienten könnte eine Operation somit eine schädigende Übertherapie darstellen. Die Etablierung einer onkologisch sicheren aktiven Überwachung gewinnt in dieser Situation zunehmend an Bedeutung, so dass klinische, radiologische und biopsiebasierte biologische Marker für die Auswahl und die Überwachung geeigneter Patienten aktuell im Fokus der Forschung stehen.AbstractThe incidence of small renal masses ≤4 cm is increasing due to the widespread use of cross-sectional imaging. The majority of these represent indolent forms, but the risk for developing metastases is reported in up to 6% of patients. Particularly in old and comorbid patients surgery might be harmful overtreatment. Thus, there is an increasing demand to establish oncologically safe active surveillance protocols. Radiographic or biopsy-based biological markers to appropriately designate candidates for active surveillance are currently the focus of research.

Strategy of robotic surgeons to exert public influence through Twitter.

Twitter is gaining growing popularity as a communication platform and potential tool to influence the public in medical matters. The aim here is to examine whether and how robotic surgeons use Twitter more influentially than other urologists.

Traditional Chinese medicine in urology

Traditional Chinese medicine (TCM) is an ancient holistic medicine based on the doctrine of Tao and Qi. Tao represents an alteration from which the polarity of Yin and Yang arises and Qi is the vitality which circulates through the body. Therapeutic concepts of TCM include acupuncture, herbal therapy, nutrition and Tuina, a form of manual therapy. TCM is now gaining increased acceptance in the Western society as a complementary therapy. Acupuncture and herbal therapy are the main forms of implementation of TCM in urology.

Traditionelle chinesische Medizin in der Urologie

Traditional Chinese medicine (TCM) is an ancient holistic medicine based on the doctrine of Tao and Qi. Tao represents an alteration from which the polarity of Yin and Yang arises and Qi is the vitality which circulates through the body. Therapeutic concepts of TCM include acupuncture, herbal therapy, nutrition and Tuina, a form of manual therapy. TCM is now gaining increased acceptance in the Western society as a complementary therapy. Acupuncture and herbal therapy are the main forms of implementation of TCM in urology.

Therapy of overactive bladder (OAB)

ZusammenfassungDer Symptomenkomplex der überaktiven Blase („overactive bladder“, OAB) mit oder ohne Inkontinenz („wet/dry“) hat mit etwa 17% in der europäischen Bevölkerung eine hohe Prävalenz und führt nicht nur zu einem hohen Leidensdruck der Betroffenen, sondern auch zu hohen Kosten für das Gesundheitswesen. Myogene, urotheliale und neurogene Faktoren führen zu noch vielfach unbekannten Veränderungen an Muskel-, Nerven- und Bindegewebe. Zur Definition, Ätiologie und Diagnostik der Erkrankung wird hier auf die vorausgegangene CME-Fortbildung „Diagnostik der überaktiven Blase (OAB)“ verwiesen. In den letzten Jahren ist etwas Bewegung in die Forschung zur OAB gekommen, sei es in Bezug auf die pathophysiologischen Modelle oder hinsichtlich neuer Therapieansätze (Entwicklung neuer Medikamente). Neben altbewähren Substanzen werden zunehmend auch neu zugelassene Wirkstoffe zur Therapie der OAB eingesetzt. Ferner spielen neben der Pharmakotherapie auch nichtmedikamentöse Therapieansätze und chirurgische Techniken weiterhin eine wichtige Rolle.AbstractOveractive bladder (OAB) is a symptom complex which is present in approximately 17 % of the European population. It is observed in the presence or absence of incontinence (wet or dry) and is associated with a high degree of psychological stress as well as high costs for the healthcare system. Myogenic, urothelial and neurogenic factors lead to frequently unknown changes of muscular, neural and connective tissue. For the definition, etiology and diagnostics of the disease the previous continuing medical education (CME) article “Diagnosis of overactive bladder (OAB)” should be consulted. In recent years some improvements have been made in OAB-related research, in terms of pathophysiological models and new pharmacological approaches with the development of new therapeutic agents. Besides classical substances, recently approved agents are increasingly being used for the therapy of OAB. Furthermore, non-pharmaceutical approaches and surgical techniques still play an important role in the therapy of OAB.