Renate Pichler

The 1 year outcome of the transobturator retroluminal repositioning sling in the treatment of male stress urinary incontinence.

1 Rehder P, Mitterberger MJ, Pichler R, Kerschbaumer A, Glodny B. The 1 year outcome of the transobturator retroluminal repositioning sling in the treatment of male stress urinary incontinence. BJU Int 2010 [Epub ahead of print]. DOI: 10.1111/j.1464-410X.2010. 09400.x 2 Rehder P, Gozzi C. Transobturator sling suspension for male urinary incontinence including post-radical prostatectomy. Eur Urol 2007; 52 : 860–6 3 Cornel EB, Elzevier HW, Putter H. Can advance transobturator sling suspension cure male urinary postoperative stress incontinence? J Urol 2010; 183 : 1459–63

The 1 year outcome of the transobturator retroluminal repositioning sling in the treatment of male stress urinary incontinence: TRANSOBTURATOR RETROLUMINAL REPOSITIONING SLING FOR MALE STRESS URINARY INCONTINENCE

Study Type – Therapy (outcomes research)
Level of Evidence 2c

Tratamiento de la incontinencia urinaria post prostatectomía con el cabestrillo retroluminal transobturatriz de reposicionamiento (Advance®): lecciones aprendidas de la experiencia acumulada

OBJETIVO: Resumir las lecciones aprendidas despues de haber realizado mas de 250 intervenciones de insercion de la malla AdVance®.La incontinencia despues de la prostatectomia es una realidad deprimente, frecuentemente subestimada por el cirujano. El esfinter urinario artificial ha sido el �gold standard� en el tratamiento de la incontinencia urinaria severa. No existe un consenso similar para la incontinencia leve-moderada. Este articulo trata sobre una operacion para la incontinencia con el objetivo de dar soporte a la laxitud del esfinter uretral despues de la prostatectomia. METODO: La hipotesis de la laxitud esfinteriana post-prostatectomia es nueva, asi como la restauracion de la continencia mediante la reubicacion proximal del cuerpo esponjoso proximal. Resumimos los trabajos que tratan este tema. Destacamos puntos seleccionados de la tecnica quirurgica, incluyendo las modificaciones que se han introducido con la experiencia. Finalmente, comparamos los primeros y ultimos 20 pacientes tratados en esta serie de 250 pacientes, analizando indicacion quirurgica, tecnica quirurgica y resultados del tratamiento. Anadimos algunas definiciones para aportar claridad. RESULTADOS: Se pudo demostrar que la posicion final del AdVance® es retroluminal, es decir 5-10 mm dorsal/detras de la luz de la uretra membranosa (= uretra esfinteriana). Comparando los primeros y ultimos 20 casos, en estos ultimos no hay ningun fracaso del tratamiento. El seguimiento a dos anos muestra una tasa de continencia del 65% en el primer grupo comparada con el 85% del segundo, teniendo en cuenta una mediana de tiempo de seguimiento corta en el segundo grupo, de 4,1 meses. La tunelizacion subcutanea del cabestrillo disminuyo significativamente el aflojamiento postoperatorio. CONCLUSIONES: El cabestrillo AdVance® es un metodo seguro de tratamiento de la incontinencia urinaria leve-moderada postprostatectomia, con ausencia de erosiones en esta serie. La hipotesis de la laxitud esfinteriana parece desempenar un papel definitivo en la fisiopatologia de la incontinencia masculina. La correccion de este descenso del soporte uretral o �prolapso� parece ser altamente eficaz. Son necesarios nuevos estudios para definir precisamente el mecanismo exacto de accion del cabestrillo AdVance®

Postchemotherapy Laparoscopic Retroperitoneal Lymph Node Dissection for Low-volume, Stage II, Nonseminomatous Germ Cell Tumor: First 100 Patients

BACKGROUND Retroperitoneal lymph node dissection (RPLND) is indicated after chemotherapy in case of radiologic incomplete remission or teratomatous elements in orchiectomy specimens. Open RPLND is associated with considerable morbidity, but technical difficulty of postchemotherapy laparoscopic RPLND (L-RPLND) can be significant; therefore, literature concerning pc L-RPLND is sparse. OBJECTIVE To evaluate feasibility and long-term oncologic outcome of postchemotherapy L-RPLND for clinical stage II disease at a single institution. DESIGN, SETTING, AND PARTICIPANTS Records of patients with nonseminomatous germ cell tumor who underwent postchemotherapy L-RPLND between 1993 and 2010 were retrospectively reviewed. Unilateral template resection was used until a bilateral nerve-sparing approach was introduced in 2004. Follow-up investigations were performed at 3-mo intervals for the first 3 yr, every 6 mo for the next 2 yr, and annually thereafter. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS This was a descriptive analysis. RESULTS AND LIMITATIONS The study cohort comprised 100 patients with stage II retroperitoneal disease (stage IIC: n=16; IIB: n=68; IIA with persisting tumor marker: n=16). Mean diameter of retroperitoneal masses before and after chemotherapy was 3.5 cm and 1.4 cm, respectively. Unilateral and bilateral templates were resected in 71 and 29 patients, respectively. Surgery was successfully completed in all but one patient, whose procedure was converted to open surgery due to bleeding. Mean operation time for unilateral and bilateral resection was 241 and 343 min, respectively. Mean blood loss was 84 ml. Postoperative complications were a large lymphocele in one patient and chylous ascites in another. Mean postoperative hospital stay was 3.9 d. L-RPLND specimens showed teratoma in 38 patients and active tumor in 2 patients. During a mean follow-up of 74 mo, one patient recurred. No recurrence was observed inside the applied surgical field. No patient died of tumor progression. After bilateral nerve-sparing postchemotherapy L-RPLND, 95.2% of patients reported antegrade ejaculation. CONCLUSIONS Postchemotherapy L-RPLND performed by experienced hands is feasible and associated with low morbidity and high oncologic efficacy.

Increased incidence of Leydig cell tumours of the testis in the era of improved imaging techniques

Study Type – Diagnostic (exploratory cohort)

Dorsal urethroplasty with labia minora skin graft for female urethral strictures

Study Type – Therapy (case series)
Level of Evidence 4

Novel therapeutic approaches for the treatment of castration-resistant prostate cancer

Highlights • New drugs approved for treatment of castration resistant prostate cancer.• Prime targets: androgen receptor, bone cells, cell division, immune system.• Several promising drugs disappointed in clinical trials.• Further efforts necessary to optimize the sequence and combinations of drugs.• New biomarkers required for stratification of patient and therapy selection.

Tumor-infiltrating immune cell subpopulations influence the oncologic outcome after intravesical Bacillus Calmette-Guérin therapy in bladder cancer

Although Bacillus Calmette-Guérin (BCG) is the most successful immunotherapy for high-risk non-muscle-invasive bladder cancer, approximately 30% of patients are unresponsive to treatment. New biomarkers are important to identify patients who will benefit most from BCG during a worldwide BCG shortage. Local immune cell subsets were measured on formalin-fixed, paraffin-embedded tissue sections of bladder cancer by immunohistochemistry, using monoclonal antibodies to tumor-associated macrophages (TAMs; CD68, CD163), B-lymphocytes (CD20) and T-lymphocyte subsets (CD3, CD4, CD8, GATA3, T-bet, FOXP3 and CD25). Cell densities in the lamina propria without invasion, at the invasive front if present, in the papillary tumor stroma, and in the neoplastic urothelium were calculated. Twenty-nine (72.5%) of 40 patients were classified as BCG responders after a mean follow-up of 35.3 months. A statistically significant association was observed for BCG failure with low density of CD4+ and GATA3+ T-cells, and increased expression of FOXP3+ and CD25+ regulatory T-cells (Tregs) as well as CD68+ and CD163+ TAMs. Survival analysis demonstrated prolonged recurrence-free survival (RFS) in patients with an increased count of CD4+ and GATA3+ T-cells. TAMs, Tregs and T-bet+ T-cells were inversely correlated with RFS. Thus, the tumor microenvironment seems to influence the therapeutic response to BCG, permitting an individualized treatment.

Diagnosis and management of pediatric urethral injuries.

Objective: The incidence of urethral injuries in children is rare due to the fact that the urethra is short, mobile and protected by the pubic bone. The management of urethral trauma in childhood remains controversial because of the limited expertise of most urologists. Material and Methods: We performed a literature review by searching the Medline database for articles published between 1975 and 2010 based on clinical relevance. Electronic searches were limited to the keywords ‘pediatric’, ‘urethral injury’, ‘trauma’ and ‘reconstruction’. Results: Retrograde urethrography is considered the gold standard for diagnosis of urethral injuries. The initial management should ensure drainage of the bladder either by suprapubic cystostomy or urethral realignment if possible: in complete anterior urethral disruption as well as in children with life-threatening pelvic and intra-abdominal injuries after posterior urethral injuries, a deferred repair after 3 months is necessary. Immediate primary suturing of disrupted and dislocated urethral ends should be avoided because of high complication rates. Primary repair, however, of the defect is possible in girls avoiding a 2-stage approach. Conclusion: The aim of therapy is minimizing remote damages such as urethrocutaneous fistulae, periurethral diverticulae, strictures, incontinence and impotence with different therapeutic management depending on classification of the injury and the presence of life-threatening injuries.

High Risk of Under-Grading and -Staging in Prostate Cancer Patients Eligible for Active Surveillance

Background Active surveillance (AS) is increasingly offered to patients with low risk prostate cancer. The present study was conducted to evaluate the risk of tumor under-grading and -staging for AS eligibility. Moreover, we analyzed possible biomarkers for predicting more unfavorable final tumor histology. Methods 197 patients who underwent radical prostatectomy (RPE) but would have met the EAU (European Association of Urology) criteria for AS (PSA<10 ng/ml, biopsy GS ≤6, ≤2 cancer-positive biopsy cores with ≤50% of tumor in any core and clinical stage ≤T2a) were included in the study. These AS inclusion parameters were correlated to the final histology of the RPE specimens. The impact of preoperative PSA level (low PSA ≤4 ng/ml vs. intermediate PSA of >4–10 ng/ml), PSA density (<15 vs. ≥ 15 ng/ml) and the number of positive biopsy cores (1 vs. 2 positive cores) on predicting upgrading and final adverse histology of the RPE specimens was analyzed in uni- and multivariate analyses. Moreover, clinical courses of undergraded patients were assessed. Results In our patient cohort 41.1% were found under-graded in the biopsy (final histology 40.1% GS7, 1% GS8). Preoperative PSA levels, PSA density or the number of positive cores were not predictive for worse final pathological findings including GS >6, extraprostatic extension and positive resection margin (R1) or correlated significantly with up-grading and/or extraprostatic extension in a multivariate model. Only R1 resections were predictable by combining intermediate PSA levels with two positive biopsy cores (p = 0.004). Sub-analyses showed that the number of biopsy cores (10 vs. 15 biopsy cores) had no influence on above mentioned results on predicting biopsy undergrading. Clinical courses of patients showed that 19.9% of patients had a biochemical relapse after RPE, among all of them were undergraded in the initial biopsy. Conclusion In summary, this study shows that a multitude of patients fulfilling the criteria for AS are under-diagnosed. The use of preoperative PSA levels, PSA density and the number of positive cores were not predictable for undergrading in the present patient collective.