Werner W. Hochreiter

Radical Cystectomy for Bladder Cancer Today—A Homogeneous Series Without Neoadjuvant Therapy

PURPOSE To investigate the effect of pelvic lymph node dissection and radical cystectomy for transitional cell cancer of the bladder on recurrence-free and overall survival, pelvic recurrences, and metastatic patterns in a homogeneous group. PATIENTS AND METHODS A consecutive series of patients undergoing pelvic lymphadenectomy and radical cystectomy between 1985 and 2000 was analyzed. All patients were staged N0, M0 preoperatively, and no patient received neoadjuvant radio/chemotherapy. Pathologic characteristics based on the 1997 tumor-node-metastasis system, recurrence-free/overall survival, and metastatic patterns were determined. RESULTS Five hundred seven patients (age 66 +/- 12 years) with a mean follow-up time of 45 months (range, 0.1 to 176 months) were analyzed. Five-year recurrence-free and overall survival were, respectively, 73% and 62% for patients with organ-confined, lymph node-negative tumors (n = 217; < or = pT2, pN0) and 56% and 49% for non-organ-confined, lymph node-negative tumors (n = 166; > pT2, pN0). Positive lymph nodes were found in 124 (24%) patients who had a 5-year recurrence-free (33%) or overall (26%) survival. Isolated local recurrences were observed in 3% of patients with organ-confined tumors (< or = pT2, pN0), 11% with non-organ-confined tumors (> pT2, pN0), and 13% with positive lymph nodes (any pT, pN+). Distant metastases developed in 25% of patients with organ-confined tumors, 37% with non-organ-confined tumors, and 51% with positive lymph nodes. CONCLUSION Despite negative preoperative staging, pelvic lymphadenectomy and cystectomy for bladder cancer reveal a high percentage of unsuspected nodal metastases (24%) that have a 25% chance for long-term survival. This procedure also ensures a low pelvic recurrence rate even in lymph node-positive patients, and patients with locally advanced cancer have a 56% probability of 5-year recurrence-free survival.

A Prospective Randomized Trial Comparing 2 Lithotriptors for Stone Disintegration and Induced Renal Trauma

PURPOSE We compare the efficacy and resulting kidney trauma of the HM3 (Dornier Medical Systems, Inc., Marietta, Georgia) and Lithostar Plus (Siemens, Issaquah, Washington) lithotriptors in a prospective randomized trial treating calix and renal pelvis stones. MATERIALS AND METHODS Patients with a solitary renal pelvic stone 2 cm. or less in diameter or a solitary calix stone 1 cm. or less in diameter were randomized for treatment with the HM3 or Lithostar Plus. Stone disintegration and dilatation of the pyelocaliceal system were evaluated by abdominal plain x-ray and renal ultrasound 1 day and 3 months after treatment. Kidney trauma was determined by measurement of N-acetyl-beta-glucosaminidase and beta-galactosidase (NAG) in pretreatment urine and 4, 12-hour urine samples collected within the first 2 days after extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc.). RESULTS Of 167 patients with 176 stones 91 were randomized to the HM3 and 85 to the Lithostar Plus lithotriptor group. The preoperative stone burden was comparable in both groups. On postoperative day 1 patients treated with the HM3 or Lithostar Plus were stone-free or had fragments 2 mm. or less (91% and 65%, p <0.001), 3 to 5 mm. (8% and 25%, p = 0.003) and 6 mm. or greater (1% and 10%, p = 0.008), respectively. Patients treated with the HM3 had less posttreatment dilatation of the collecting system (p = 0.01). Obstructive pyelonephritis occurred in 1% of the HM3 and 8% of the Lithostar Plus group (p = 0.02). Re-treatment rate was 4% in the HM3 and 13% in the Lithostar Plus group (p = 0.05). Mean excretion of urinary NAG per treatment (including re-treatments) was comparable in both groups but NAG excretion in relation to stone volume and shock wave number 12 to 24 hours after ESWL was significantly higher in the HM3 group (p <0.05). At 3-months postoperatively 89% of the patients treated with the HM3 and 87% treated with the Lithostar plus were stone-free with no dilatation of the collecting system. CONCLUSIONS This prospectively randomized study indicated that the HM3 is still the gold standard in regard to disintegration of pelvicaliceal stones. Stone disintegration with the HM3 is better with fewer shock waves, re-treatment rate is lower, and posttreatment dilatation of the collecting system and complications such as obstructive pyelonephritis are less than those with the Lithostar Plus. ESWL induced kidney trauma is minor and resolves within 2 days. The HM3 delivers more energy per shock wave into the kidney as assessed by urinary NAG.

Holmium Laser Enucleation of the Prostate Combined with Electrocautery Resection: The Mushroom Technique

PURPOSE The holmium laser allows bloodless enucleation of the prostate. A problem is how to remove a whole enucleated, free floating, large prostatic lobe from the bladder. A mechanical morcellator has been used to achieve tissue fragmentation but aspiration of and damage to the bladder wall are risks. Using the mushroom technique holmium laser enucleation and electrocautery resection can be combined without compromising the bloodless advantages of the laser procedure. MATERIALS AND METHODS We treated 156 patients with benign prostatic hyperplasia using a holmium laser with the mushroom technique. Preoperatively all patients were assessed using the International Prostate Symptom Score, maximum urine flow, ultrasound estimation of prostate volume and post-void residual urine, and pressure flow study. Laser enucleation of the prostatic lobes was performed at 66 W. Instead of releasing the lobes into the bladder they were left attached at the bladder neck by a narrow mushroom-like pedicle. At that point the vascular supply was almost completely interrupted and the lobes could easily be electroresected into small pieces without bleeding. Patients were followed 6, 12 and 24 months after the procedure. RESULTS No patient had significant blood loss or signs of the transurethral resection syndrome. A total of 19 patients were treated while under oral anticoagulation without major bleeding problems. Complete followup was available on 125 patients. Median baseline International Prostate Symptom Score decreased from 20 to 3 at 6 months (p <0.05) and remained stable at 12 and 24 months. Median maximum urine flow increased from 8 to 20 ml. per second at 6, 12 and 24 months (p <0.05). Median baseline post-void residual urine decreased from 190 to 30 ml. at 6 months (p <0.05) and remained low at 20 and 30 ml. at 12 and 24 months, respectively. Urodynamic evaluation preoperatively and 6 months postoperatively was available in 83 cases. Relief of obstruction was documented with a statistically significant decrease in median detrusor pressure at maximum urine flow from 87 to 48 cm. water (p <0.05). CONCLUSIONS Combining holmium laser enucleation and prostate electroresection with the mushroom technique is safe, efficient and bloodless surgical treatment for benign prostatic hyperplasia with sustained relief of obstruction. With this technique there is no need for additional devices, such as a mechanical tissue morcellator.

INFLUENCE OF STENT SIZE ON THE SUCCESS OF ANTEGRADE ENDOPYELOTOMY FOR PRIMARY URETEROPELVIC JUNCTION OBSTRUCTION: RESULTS OF 2 CONSECUTIVE SERIES

PURPOSE We evaluated the influence of stent size in 2 consecutive series of unselected patients in whom primary ureteropelvic junction obstruction was managed by antegrade endopyelotomy and stenting with a 14 or 27Fr stent at the level of the incision. MATERIALS AND METHODS Antegrade endopyelotomy was performed in 132 patients with primary ureteropelvic junction obstruction. The endopyelotomy was stented for 6 weeks. In 77 patients (group 1) a 14/8.2Fr percutaneous endopyelotomy (Smith) catheter was used. In 55 patients (group 2) a modified 14/8.2Fr Smith catheter was over pulled with a 27Fr wound drain. The wound drain was removed after 2 to 3 weeks and the standard 14/8.2Fr stent remained in place for another 3 to 4 weeks. Success at 6 to 8 weeks, and 6 and 24 months postoperatively was based on clinical evaluation, and excretory urography and/or diuretic renography. Thereafter clinical and ultrasound followup was performed every 2 to 3 years. RESULTS Preoperatively data on the risk factors of large pyelocaliceal volume and impaired renal function were similar in the 2 groups. The overall success rate was 70% in group 1 at a median followup of 67 months (range 2 to 118) and 94% in group 2 at a median followup of 23 months (range 2 to 52). The early success rate after 6 to 8 weeks in groups 1 and 2 was 83% and 94%, respectively. The long-term success rate after 2 years was 71% and 93%, respectively. Perioperatively and postoperatively the incidence of complications was 16% in group 1 and 24% in group 2. When group 2 complications due to a lack of experience with the new stent were excluded from analysis, the remaining 15% complication rate was comparable to that in group 1. Mean pyelocaliceal volume decreased significantly in each group and remained stable. Split renal function did not change preoperatively to postoperatively with no significant difference in the 2 groups. CONCLUSIONS Stenting an antegrade endopyelotomy with a modified 27Fr instead of a 14Fr catheter seems to increase the early and, even more impressively, the long-term success rate to a level similar to that of open pyeloplasty.

National Institutes of Health (NIH) Chronic Prostatitis Symptom Index. The German version

| Der Urologe [A] 1•2001 16 Die chronische abakterielle Prostatitis – gekennzeichnet durch Schmerzen im Beckenbereich und unterschiedliche Miktionsbeschwerden – ist ein schlecht definiertes, wenig erforschtes und schwierig zu behandelndes Syndrom. Die bis vor kurzem weit verbreitete Klassifikation in akute bakterielle, chronisch bakterielle und abakterielle Prostatitis und die Prostatodynie wurde 1995 nach einem Konsensus-Meeting des „National Institute of Diabetes and Digestive and Kidney Diseases“ (NIDDK) durch die mittlerweile weltweit akzeptierte Prostatitisklassifikation der „National Institutes of Health“ (NIH) ersetzt [1]. Damit wurde für die Diagnostik eine praktikable Hilfe bei der Einteilung von Prostatitispatienten geschaffen [2]. Nachdem eine verbesserte Klassifikation von Patienten mit chronischer Prostatitis nun möglich war,bestand das Problem, wie der Verlauf beurteilt werden kann.Auf dem Gebiet der benignen Prostatahyperplasie (BPH) hat man erkannt, dass geeignete Symptomscores ein sehr hilfreiches Instrument zur Verlaufsbeurteilung darstellen. Aus diesem Grund wurde vom „NIH Chronic Prostatitis Clinical Research Network“ ein prostatitisspezifischer Symptomindex erarbeitet, der die 4 Hauptaspekte der Prostatitis berücksichtigt: Schmerzen, Miktion, Symptome und Lebensqualität [3]. Dieser „Chronic Prostatitis Symptom Index“ (CPSI) beinhaltet 9 Fragen, ist leicht verständlich und kann in kurzer Zeit von den Patienten ausgefüllt werden. Das Ziel unserer Gruppe war es, den CPSI auf deutsch zu übersetzen und dabei sprachliche Charakteristiken so zu berücksichtigen, dass der Fragebogen in allen deutschsprachigen Ländern verwendet werden kann. Dabei wurde nach einer üblichen Technik, wie sie für validierte Fragebögen verwendet wird, vorgegangen. Zuerst erfolgte die Übersetzung vom englischen ins deutsche durch 2 unabhängige Übersetzer deutscher Muttersprache. Ein weiterer Übersetzer deutscher Muttersprache koordinierte und,sofern nötig,verbesserte die beiden Versionen. Diese überarbeitete Fassung wurde von einem Übersetzer englischer Muttersprache und fließenden Deutschkenntnissen ins englische zurückübersetzt. Sämtliche Übersetzungen wurden von 3 zweisprachigen Experten begutachtet, nochmals im Detail überarbeitet und dann als definitive Version verabschiedet (Abb. 1). Im Rahmen von Prostatitisstudien ist zu empfehlen, dass die vorliegende deutsche Version des CPSI zur Beurteilung des Verlaufs miteinbezogen wird. Aufgrund der in den USA bisher gemachten Erfahrungen erscheint es auch sinnvoll, den NIH-CPSI im täglichen klinischen Alltag zu verwenden, um Symptome und Lebensqualität von Patienten mit chronischer Prostatitis zu dokumentieren und den Verlauf verfolgen zu können. Literatur

Non-Inflammatory Chronic Pelvic Pain Syndrome Can Be Caused by Bladder Neck Hypertrophy

PURPOSE Little is known about the etiology of the non-inflammatory Chronic Pelvic Pain Syndrome (CPPS, NIH category IIIb). We conducted this study to determine whether endoscopic and urodynamic evaluation provide objectively measurable parameters that may support the rationale of therapeutic strategies for patients who failed to respond to medical treatment of non-inflammatory CPPS. MATERIALS AND METHODS The 48 patients included in this study fulfilled the NIH criteria for non-inflammatory chronic pelvic pain syndrome category IIIb. All patients had received multiple courses of antimicrobial and/or anti-inflammatory drugs, but suffered recurrent symptoms. An endoscopic and urodynamic evaluation was performed after any medical treatment had been discontinued for at least 6 weeks. RESULTS At urethrocystoscopy, no patient had endoscopic evidence of obstruction due to urethral stricture, but 29 patients (60%) were found to have significant bladder neck hypertrophy. At urodynamic evaluation, these 29 patients had an increased detrusor opening pressure DOP (49 vs. 29 cmH(2)O), an increased detrusor pressure at maximal flow P(det,Q(max)) (55 vs. 34 cmH(2)O), a decreased maximal flow Q(max) (10 vs. 17 ml/s) and an increased postvoid residual urine PVR (67 vs. 17 ml) when compared to the 19 patients with a normal appearing bladder neck. These differences were statistically significant (p<0.05). When assessed with the NIH Chronic Prostatitis Symptom Index (CPSI) the two groups showed no difference in the domains of pain and quality of life impact but urinary symptoms were significantly more pronounced in the presence of bladder neck alterations. CONCLUSIONS Patients with non-inflammatory CPPS who fail to respond to medical treatment with antibiotics and/or anti-inflammatory drugs may have morphological alterations in form of bladder neck hypertrophy. This can be suspected when urinary symptoms, residual urine and decreased Q(max) are present. These can be assessed by non-invasive methods. Endoscopic and/or urodynamic evaluation seem to be justified in these patients in order to establish the diagnosis, consider alpha-adrenergic blockade and avoid unnecessary antibiotic treatment.

Urogenitale Infektionen im Alter

ZusammenfassungDie zunehmende Inzidenz asymptomatischer Bakteriurien, aber auch symptomatischer Harnwegsinfekte beim alternden Menschen macht eine differenzierte Betrachtung dieser Problematik unter Beachtung altersspezifischer medizinischer und sozialer Risikofaktoren notwendig. Im Vordergrund stehen dabei die zunehmende Pflegebedürftigkeit, alters-, aber auch geschlechtsspezifische komplizierende Faktoren wie subvesikale Obstruktion, Adnexinfektionen und Inkontinenz, sowie die Notwendigkeit der Katheterisierung. Auch spezifische Alterserkrankungen wie Diabetes mellitus, die veränderte Pharmakodynamik antimikrobiell wirksamer Substanzen und Veränderungen der vaginalen Vorfeldbesiedlung stellen erhöhte Anforderungen an potentielle Therapiestrategien. Die aus dieser Problematik resultierenden urologischen Implikationen sind bis heute nicht ausreichend erforscht und bedürfen weiterer “evidence based” Aufarbeitung.AbstractThe increasing incidence of asymptomatic bacteriuria and symptomatic urinary tract infections in the elderly requires a detailed consideration of this problem including age-specific medical and social risk factors. The increasing need for care, age- and gender-related complicating factors such as subvesical obstruction, adnexal infections, and incontinence, and the need for catheterization are predominant. Specific age-related diseases such as diabetes mellitus, pharmacodynamic alterations of antimicrobial substances, and changes in the vaginal colonization make increased demands on therapeutic strategies. Urologic implications resulting from this set of difficulties have not yet been investigated sufficiently and need further evidence-based work-up.

Chronic pelvic pain syndrome and voiding dysfunction

Chronic prostatitis/chronic pelvic pain syndrome is a disease that is mainly characterized by three parameters: pain in the suprapubic and pelvic area, presence or absence of white blood cells in expressed prostatic secretions, and voiding disorders of various degrees. The causative factors underlying this very common condition are poorly understood. Therapeutic options (ie, antimicrobial treatment) often are based on the presence of an inflammatory reaction in the expressed prostatic secretions, but the benefit of recurring or prolonged courses of antimicrobial agents is highly variable. Observations have been made regarding functional and structural changes in the lower urinary tract that are suggestive to have an impact on the pathogenesis of chronic pelvic pain syndrome.

Tipps und Tricks der nerverhaltenden Zystektomie

ZusammenfassungDas Ziel der radikalen Zystektomie mit nachfolgender Harnableitung ist es, ein sicheres onkologisches Ergebnis mit einem zufrieden stellenden funktionellen Ergebnis zu kombinieren. Rezente Erkenntnisse zur Anatomie, Physiologie und Innervation der Beckenorgane haben zu einer modifizierten, nerverhaltenden Operationstechnik geführt. Eine Vielzahl von Studien konnten zeigen, dass das onkologische Ergebnis, insbesondere die Rate an Lokalrezidiven, nach nerverhaltender Zystektomie im Vergleich zur konventionellen Technik nicht erhöht ist. Eine nerverhaltende Zystektomietechnik ist für das funktionelle Ergebnis nach orthotopem Blasenersatz hinsichtlich des Kontinenzstatus und der erektilen Funktion von großer Bedeutung. Voraussetzungen für einen Nerverhalt sind fundierte anatomische Kenntnisse und eine subtile Operationstechnik. Neueste chirurgische Entwicklungen, wie die prostata- und samenblasenschonende Operationstechnik zeigen, dass es in Zukunft möglich sein wird, die untere Harntrakt-, aber auch die Sexualfunktion nach radikaler Zystektomie weitgehend wiederherzustellen.AbstractThe aim of radical cystectomy with subsequent urinary diversion is to combine a safe oncological outcome with a satisfactory lower urinary tract function. Recent findings on the anatomy, physiology and nerve supply of the pelvis have resulted in a modified nerve-sparing cystectomy technique. A number of studies have shown that the oncological outcome is not compromised by such a technique; in particular the rate of local recurrences is not enhanced. Nerve-sparing cystectomy is of importance for the lower urinary tract function, including continence status after orthotopic bladder substitution and erectile function. Prerequisites for a nerve-sparing technique are a profound knowledge on the nerve supply of the pelvic organs and a subtle surgical technique. Recent surgical developments, for example in prostate and seminal vesicle sparing cystectomy techniques, indicate that it will be feasible to restore lower urinary tract and also sexual function after radical cystectomy and orthotopic bladder substitution.

Anti-Inflammatory Therapies for Chronic Prostatitis

Abstract Anti-inflammatory therapy is very commonly prescribed in men with chronic nonbacterial prostatitis, or chronic pelvic pain syndrome. This practice is based on clinical experience rather than clinical trial data. This paper reviews the evidence to support the use of anti-inflammatory therapy in chronic prostatitis, and presents some considerations for future research.