Vom Dorp F

Role of lymphadenectomy in patients with invasive urothelial carcinoma of the bladder

High-grade urothelial carcinomas of the bladder represent high-risk tumors and despite radical surgery and pelvic lymph node dissection patients have a lifelong risk for tumor progression and metastases. Since extended lymph node dissection detected metastases outside the fields of normal pelvic lymphadenectomy, it was concluded that all patients undergoing radical cystectomy should receive extended lymph node dissection. The article reviews published data discussing the question of whether lymph node dissection has prognostic or therapeutic relevance.ZusammenfassungDas High-grade-Urothelkarzinom der Harnblase stellt für den Patienten ein Hochrisikotumor dar. Selbst durch die radikale Zystektomie und pelvine Lymphadenektomie weisen Patienten mit invasiven Harnblasenkarzinomen ein hohes Risiko für eine lymphogene und hämatogene Metastasierung auf. Die Tatsache, dass bei extendierter Lymphadenektomie lymphogene Metastasen außerhalb der Grenzen der normalen pelvinen Lymphadenektomie gefunden wurden, legt nahe, allen Patienten eine extendierte Lymphknotendissektion zukommen zu lassen. In der vorliegenden Arbeit werden publizierte Daten zu dieser Thematik zusammengefasst, die die Frage nach der prognostischen und der therapeutischen Bedeutung der Lymphkontendissektion im Rahmen der radikalen Zystektomie bearbeiten.AbstractHigh-grade urothelial carcinomas of the bladder represent high-risk tumors and despite radical surgery and pelvic lymph node dissection patients have a lifelong risk for tumor progression and metastases. Since extended lymph node dissection detected metastases outside the fields of normal pelvic lymphadenectomy, it was concluded that all patients undergoing radical cystectomy should receive extended lymph node dissection. The article reviews published data discussing the question of whether lymph node dissection has prognostic or therapeutic relevance.

Endoscopic management of urethral stricture

Great progress has been seen in the treatment of urethral strictures since the first endoscopic urethrotomy was performed in 1893 by Felix Martin Oberländer in Dresden, Germany. With the introduction of endoscopic laser therapy and the variety of urethral reconstruction methods other ways to treat this important urologic entity became available. Despite this progress, urethrotomy still represents the preferred treatment concept for primary, short and bulbar urethral strictures. In this study we performed a 2-year retrospective analysis of 20 patients undergoing primary endoscopic urethrotomy by single bulbar or penile narrowing. A high incidence of recurrence was seen in 70% of the patients. Nevertheless, direct vision urethrotomy represented a safe and effective transitory method to treat these patients. Moreover, 80% of the patients preferred, in cases of recurrence, a repeated urethrotomy as the treatment of choice. Although the long-term results evidence high relapse rates after the first and second procedures, there have been no sufficient data in the literature which support the use of other methods. Furthermore, primary endoscopic management of urethral strictures remains a simple, safe, and cost-effective procedure that should be indicated before more invasive approaches are taken to provide relief to these patients from this limiting problem.

[Urine-based cytological diagnosis against the background of the new histopathological classification].

Urinary cytology is a basic adjunct to cystoscopy and transurethral resection in the diagnosis and characterization of high-grade urothelial carcinomas of the bladder. According to the new WHO classification the former tumor grading G1-3 for non-invasive carcinomas has been replaced by a separation into low-grade and high-grade urothelial carcinomas. An interesting question is where the former non-invasive G2 carcinomas will be positioned in this new classification. In a retrospective analysis we focused on 44 patients with pTaG2 and 17 patients with pT1G2 carcinomas and found that this group of tumors is cytologically heterogeneous but easily differentiated into low-grade and high-grade lesions. A cytometrical analysis significantly underlines the results of the cytological diagnostics. High-grade tumors show a higher recurrence and progression rate. Cytological diagnostics can therefore assist in differentiating low-grade from high-grade urothelial carcinomas.

[Use of silicon chip technology to detect protein-based tumor markers in bladder cancer].

The protein structure of human tumor tissue has a significant influence on the molecular attributes. It was demonstrated that the individual prognosis of tumor patients is among other things dependent on molecular tumor tissue characteristics.A promising marker is E-cadherin, an adhesion glycoprotein which plays a central role in the mediation of cell-cell contacts. Aberrant E-cadherin expressions were described in several tumors such as in bladder cancer. This was also found to be correlated with tumor invasion and survival. There are hardly any fast, quantitative and easily automated protein assays in everyday practice which can analyze several markers at the same time. With silicon chip technology we have a new detection and measurement method which makes it possible to give a quantitative analysis of numerous different proteins in tissue, urine, or serum in a few minutes.

The management of cutaneous metastases

ZusammenfassungEine seltene Form des Tumorprogresses bei urologischen Tumoren ist die kutane Metastasierung. Sie ist ein Indiz für eine schlechte Prognose des Patienten. Die Erscheinungsform der kutanen Metastasen ist variabel, entscheidend in der Diagnostik ist es, eine kutane Metastasierung in die Differenzialdiagnose einzubeziehen. Die Therapie erfolgt meist in palliativer Intention, wobei die Lebensqualität des Patienten an erster Stelle stehen sollte. Im Vordergrund steht die Symptomkontrolle. Diese wird zu einem großen Anteil durch die lokale Wundpflege erreicht. Bei der Applikation einer Chemotherapie steht die Behandlung des systemischen Progresses im Vordergrund. Zur lokalen Tumorkontrolle findet die Metastasenchirurgie aber auch die lokale Strahlentherapie Einsatz.AbstractCutaneous metastases are rare and usually signify a poor prognosis. The manifestation of cutaneous metastases is variable; crucial to their diagnosis is their inclusion in the differential diagnosis. The therapy occurs mostly with palliative intention. The quality of life of the patient should take first priority. A combination chemotherapy is usually carried out because of systemic progress. For local tumor control and wound care, metastasis surgery and radiotherapy are used.

[Comparison of perioperative methylene blue-stained and permanent Papanicolaou-stained urine cytology to detect patients with high-grade urothelial cancer or the urinary bladder. Part 1].

INTRODUCTION The aim of the study was to investigate whether intraoperative methylene blue-stained and permanent Papanicolaou-stained urine cytologies show comparable accuracy in detection of high-grade urothelial carcinoma. PATIENTS AND METHODS The study included 130 patients; 50 patients were without malignancy (25 follow-up, 25 with hematuria). In 80 patients transurethral resection due to urothelial carcinoma was performed. Per patient two cytology specimens were prepared: one immediate methylene blue-stained specimen, which was evaluated by the surgeon, and one Papanicolaou-stained permanent cytology slide, which was blinded and evaluated by one urologist. RESULTS Cytology results of all patients without malignancy were unsuspicious irrespective of the staining method. Of 80 patients with urothelial carcinoma, 50 showed a low-grade tumor. Sensitivity of tumor detection was 20 and 30% for methylene blue/Papanicolaou-stained slides, respectively. Among 30 patients with high-grade carcinoma, 10 were detected by methylene blue cytology and 30 by Papanicolaou-stained slides, corresponding to a sensitivity of 40 and 100%, respectively. CONCLUSIONS The results of standard Papanicolaou-stained urine cytology in the detection of clinically relevant high-grade urothelial carcinoma are excellent. The quality of cytological tumor detection by methylene blue-stained cytology made by different evaluators is insufficient in our opinion.

[Non-muscle invasive bladder cancer: safety of postoperative EMDA-assisted instillation of mitomycin].

BACKGROUND The immediate instillation of mitomycin after transurethral resection of bladder tumor (TURBT) is widely used and recommended in the guidelines. Recently it was shown that pre-TURBT intravesical electromotive drug administration (EMDA) of mitomycin reduces the recurrence rate of non-muscle invasive bladder cancer. Our aim was to describe the pharmacokinetics and patient safety after post-TURBT EMDA. METHODS We performed a single centre study with 25 patients diagnosed with non-muscle invasive bladder cancer. All patients underwent complete resection of all visible tumors and post-TURBT intravesical electromotive drug administration (EMDA) of mitomycin (40 mg) for 30 min. Blood samples were taken before starting the electrical current and 15, 30, 60, and 120 min after starting the procedure for quantification of mitomycin serum levels. RESULTS In 24 patients, the measured serum level of mitomycin was below the detection threshold of 50 ng/ml. In one patient serum level was elevated 15 min (155 ng/ml) and 30 min (65 ng/ml) after intravesical instillation. Nine patients reported a slight tingling sensation in the bladder during mitomycin administration. Discreet pressure in the suprapubic area was reported by one patient. One patient had a first degree skin burn at the site of one skin electrode. CONCLUSION Postoperative EMDA with mitomycin is a safe procedure. The measured mitomycin serum levels were below toxic concentrations. These findings encourage the initiation of large randomized controlled trials with postoperative EMDA-assisted instillation of mitomycin to test its influence on the recurrence rate of non-muscle invasive bladder cancer.

[Intravesical therapy of non-muscle invasive bladder tumors].

ZusammenfassungDie Instillationsbehandlung des nichtmuskelinvasiven Urothelkazinoms der Harnblase besitzt eine lange Tradition. Im Falle der Low-grade-Tumoren steht die Rezidivprophylaxe im Vordergrund, da mit einer Tumorprogression nicht zu rechnen ist. Im Falle der High-grade-Tumoren steht die Verhinderung der Progression im Vordergrund. Die vorliegende Arbeit setzt sich mit beiden Aspekten kritisch auseinander.AbstractIntravesical therapy of non-muscle invasive bladder tumors has a long tradition. With regard to low grade tumors prevention of tumor recurrence remains the main endpoint, whereas in high grade tumors prevention of tumor progression is the main aim of intravesical treatment. The following article critically discusses these aspects of non-muscle invasive bladder tumors.Intravesical therapy of non-muscle invasive bladder tumors has a long tradition. With regard to low grade tumors prevention of tumor recurrence remains the main endpoint, whereas in high grade tumors prevention of tumor progression is the main aim of intravesical treatment. The following article critically discusses these aspects of non-muscle invasive bladder tumors.

[How should urologists perform implantation of subcutaneous central venous port systems? A single center experience of 347 cases].

BACKGROUND Since 1999 urologists at the University of Essen in Germany have performed subcutaneous implantation of venous port systems, controlled by intravasal ECG. METHODS Between December 1999 and June 2011 implantation of venous port systems was performed in 241 male (69.5%) and 106 (30.5%) female patients. The port systems were implanted subcutaneously above the pectoralis major muscle under local anesthesia. If it was not possible to isolate the cephalic vein or safe catheter implantation was not feasible, puncture of the subclavian vein was performed. RESULTS The median follow-up was 491.6 days (2-2568), and 163.254 catheter days (mean 239 days, range 2-2604) were documented. During the follow-up period 191 (55.1%) patients died. The mean surgical implantation and explantation time was 36.5 min (14-85 min) and 25.4 min (10-46 min), respectively; 79.7% were implanted and controlled by ECG. Altogether, 390 devices were used in 379 surgical procedures, 355 implantations (91.1%) and 35 explantations (8.9%). Implanted vessels were the cephalic vein in 303 patients (85.6%) and the subclavian vein in 51 (14.4%) patients. Of 35 explanted devices, the explantation was necessary due to complications in 28 (8.0%) cases: infection n=6 (1.7%, 0.036 per 1,000 catheter days), occlusion n=8 (2.3%, 0.049 per 1,000 catheter days), dislocation n=7 (2.0%, 0.042 per 1,000 catheter days), deep vein thrombosis of the upper extremity n=6 (1.7%, 0.037 per 1,000 catheter days), and clotting n=1(0.3%, 0.006 per 1,000 catheter days). Premature catheter removal (<30 days post-op) was required in six cases (1.9%, 0.036 per 1,000 catheter days) due to complications: three catheter dislocations/malfunctions (0.9%, 0.019 per 1,000 catheter days), one port-related infection, one pocket port infection, and one deep vein thrombosis of the upper extremity (0.3%, 0.006 per 1,000 catheter days). Other problems described in the literature like pneumothorax, vein perforation, or pinch-off syndrome did not occur. CONCLUSIONS Implantation of port systems with ECG control of the catheter tip position is related to a few cases of adverse events and good surgical outcomes. Furthermore, it has also shown great advantages in offering immediate support and early therapy initiation with a fast learning curve for the training urologists. The results of the presented analysis are comparable to those of surgical or radiological departments reported in the literature and provide good evidence that this procedure should be extended to urological centers with a high volume of chemotherapy patients.

Exfoliative urine cytology in the treatment of bladder cancer

Urine cytology in addition to cystoscopy and transurethral resection is an integral part in diagnostic and follow-up of transitional carcinomas. The WHO-Classification of 2004 distinguishes between low grade and high grade tumours. Cytological diagnosis had to be adjusted to this new classification.Above all cytology has to detect high grade lesions in a reliable manner. The sensitivity for these lesions ranges between 85-95%. Well differentiated transitional cell carcinomas show marginal nuclear alterations compared to normal urothelial cells. Therefore the cytological low grade diagnosis is needless. Well differentiated papillary tumours can be detected with conventional cystoscopy in nearly 100 percent of all cases. This subtype of urothelial carcinomas is characterized by a very low rate of tumour progression despite a relevant rate of tumour recurrence. A negative cytology result combined with a cystoscopically proven papillary bladder tumour implies low grade disease with low risk of tumour progression.