Free paper -posters - doctors

E Hernes^1, E Hem^2, A Kyrdalen^3, R Kvåle^1, O Klepp^4, K Axcrona^5, SD Fosså³

¹Cancer Registry of Norway, Oslo University Hospital, The Norwegian Radium Hospital, ²Dept. of Surgery, Akerhus University Hospital, Nordbyhagen, ³Cancer Clinic, Oslo University Hospital, The Norwegian Radium Hospital, ⁴Dept. of Oncology, Ålesund Hospital, ⁵Dept. of Surgery, Oslo University Hospital, The Norwegian Radium Hospital, Norway

Eivor.Hernes@kreftregisteret.no

 

Background: Evaluation of a country’s management of prostate cancer patients requires population-based prognostic and therapeutic parameters, thus, in 2004 a Norwegian Prostate Cancer Registry (NoPCR) was established as a sub-registry of the CR. Initial management of the year 2004 pts was evaluated based on 2003 EAU guidelines.

Method: TNM categorization, PSA and Gleason score were recorded together with initial treatment. Patients with T1-3N0-XM0-X disease, age ≤75 years, and good health were identified as “candidates for immediate curative local treatment” (CurCands), and were allocated to risk groups.

Results: Compared to CR registration the NoPCR compliance rate was 96% (N=3833). Among 1650 CurCands such treatment was performed in 57% of low-risk pts (287 of 500), and in 64% of intermediate- and high-risk pts (735 of 1150). In low-risk pts curative treatment was more likely with T2 tumours. In intermediate- and high-risk CurCands, PSA was the strongest factor determining the performance of curative treatment. Adjuvant post-RP radiotherapy was applied in only 4 of 142 pts with tumour-involved margins.

Conclusion: According to the NoPCR initial prostate cancer management in Norway was largely in accordance with the 2003 EAU guidelines, though there was some evidence for “undertreatment” of intermediate- and high-risk pts. Some improvement of the NoPCR’s data collection is warranted. National prostate cancer registries may contribute to improvement of these pts’ medical care.

 

               

C Gade, M Mortensen, M Borre

Department of Urology, Aarhus University Hospital, Skejby, Denmark

christinagade@hotmail.com

 

Aim: To characterize patients with tumour negative prostate biopsies at first test prior to later prostate cancer diagnosis and radical prostatectomy (RP).

Patients and materials: Data concerning 535 radical prostatectomized patients prospectively collected for “the Aarhus PC-project”.

Results: Totally 79 (13%) radical prostatectomized patients had tumour negative prostate biopsies prior to later cancer diagnosis being characterized as typical young (<63 years; p=0.005) men with PSA > 10 ng/mL (p<0.001), cT1c (65%), Gleason 6 or 7 (75%) tumours in a few (1-2) positive biopsies (p=0.02). They postoperatively typically harboured pT2c tumours (62%), while only 13 (16%) had pT3 disease (p=0.01). After treatment there existed no statistically significant difference in risk of disease recurrence (p=0.97) compared to patients with tumour positive biopsies at first biopsy test.

Conclusion: Radical prostatectomized patients with a set of tumour negative prostate biopsies are characterized as relative young men with non-palpable tumours and high PSA. Postoperatively these patients match radical prostatectomized patients with no previously tumour negative biopsy tests and have a similar outcome. Relatively young men with inexplicable high PSA should be re-biopsied if biopsies at first test do not point out tumour.

 

               

M Dimmen, K Axcrona, B Brennhovd

Radiumhospitalet, Dept for Surgical Oncology, Rikshospitalet HF, Oslo, Norway

magne.dimmen@radiumhospitalet.no

 

Aim: To evaluate the diagnostic yield of perineal prostate biopsies in patients with elevated PSA and previous negative transrectal biopsies.

Material: 57 patients referred to our hospital for perineal prostate biopsies over a period of 18 months. Patients were given iv sedation and local anaesthetic, biopsies were obtained TRUS-guided. 43 patients had an MRI of the prostate prior to biopsy.

Results: 57 patients had previously had a mean of 2,47 biopsy series (0-7, median 2), pre biopsy PSA was mean 20,4 (4,3-229, median 12). A mean of 19,5 biopsy cores were taken (1-36).

Of 57 patients, 32 were diagnosed with cancer. 13 patients have been operated with robotic assisted prostatectomy and 8 are scheduled for operation. 2 patients have started AD and EBRT. 1 patient had a recurrence of rectal cancer and died within a few months. 7 patients are followed on active surveillance. Of 13 patients operated, 5 had a stage pT2c with Gleason grade 3+4 or 4+3, 7 had a pT3 with Gleason grades 4+3 (3), 4+4 (3) and 4+5 (1). Few complications were registered relating to the biopsy procedure; one patient had bacteraemia and two patients had acute urinary retention.

Conclusion: Perineal prostate biopsy is a simple technique, but requires iv sedation. The technique can be used in patients with a closed anal orifice after previous surgical treatment.

Prostate cancer was diagnosed in 56% of the patients, 78% of these were regarded as clinically significant and have started active treatment.

C Lindberg, M Annerstedt, S Gudjonsson, R Hilmarsson, O Bratt

Department of Urology, University of Lund, Sweden

christian.lindberg@skane.se

 

Aim: The EAU Guidelines no more recommend a pelvic lymphadenectomy limited to the obturator fossa (L-PLND) for prostate cancer, but a more extensive one including tissue also around the external and internal iliac arteries (E-PLND). This recommendation relies on studies reporting that up to twice as many patients with metastases can be identified, with only slightly more complications. However, these studies emanate from high volume centres. We wanted to investigate whether the results of those studies could be repeated in a Nordic hospital with lower patient volume.

Subjects and methods: From 2002 to September 2007 172 patients were operated with radical prostatectomy and PLND at the University Hospital of Lund, 108 with E-PLND and 64 with L-PLND.

Results: A median of 17 lymph nodes were identified with E-PLND but only 7 with L-PLND. In the E-PLND group 10 of the 22 patients with metastases had such exclusively outside the obturator fossa. Complications were more common after E-PLND: time with drain (median 12 vs. 4 days), lymphoceles (18 vs. 9 %) pulmonary embolism (4.6 vs. 1%) and other complications (9 vs. 2 %).

Conclusions: Almost half of the patients with metastases are misclassified by L-PLND. Hence, E-PLND must be performed if it is important to identify the patients with lymph node metastases. However, in our hands complications were more common than reported by high volume centres. This may imply that E-PLND should be performed by specific high volume surgeons only.

 

               

W Soller, T Jiborn, G Ahlgren, P Elfving, A Bjartell

Department of Urology, Malmoe University Hospital, Malmoe, Sweden

wolfgang.soller@skane.se

 

Aim: To report initial results after implementation of robot-assisted approach as our standard technique for retroperitoneal pelvic lymph node dissection (RPLND) in patients with newly diagnosed prostate cancer.

Material and methods: Between Dec 2006 and Dec 2008 we performed 123 cases of RPLND in patients with prostate cancer, using the Da Vinci ? system. Among these patients, 46 were scheduled for radiotherapy with curative intent and 77 patients underwent robot-assisted radical prostatectomy simultaneously. Data were collected prospectively. In the first 79 patients we removed tissue from the obturator fossa with surrounding (standard RPLND, SRPLND). From June 2008 (n=34), we used an extended template also including tissue along the external iliac vessels, the bifurcation area and the internal iliac artery (extended RPLND, ERPLND).

Results: Mean operation time was 128 min for SRPLND vs. 134 min for ERPLND and blood loss 44 ml vs. 71 ml. An increased number of lymph nodes were obtained at ERPLND compared to SRPLND (mean 25 vs. 20). Lymph node metastases were detected in 17% of cases. Postoperative complications comprised lymphocoele with infection (1), thrombosis (1), pulmonary embolism (1) and ureteral occlusion (1).

Conclusions: Robotic-assisted surgery enables extended RPLND with short operation time, minimal blood loss, relatively few complications and a significant increase in number of lymph nodes harvested.

 

               

M Borre

Department of Urology, Aarhus University Hospital, Skejby, Denmark

borre@ki.au.dk

 

Objectives: To evaluate and compare the oncological outcome as regards surgical margin status and PSA recurrence (PSAR) rates in patients undergoing the first 100 robot-assisted laparoscopic radical prostatectomy (RALP) procedures with consecutive patients treated with open radical prostatectomy (RP) inside the same period of time.

Patients and materials: Inside 2005 and 2008 the first 100 RALP procedures took place in Aarhus together with another 172 patients undergoing RP. Data has prospectively been collected for “the Aarhus PC-project”. Median follow-up was 19.5 months.

Results: A preoperative patient selection was observed. The robotic assisted group thereby had significantly more favorable preoperatively tumor characteristics. PSAR was demonstrated in highly statistically significant favor of RALP (p<0.001). Tumour positive surgical margins (PSM) were observed in 36% and 18% in RP and RALP respectively (p=0.01), however concerning pT2 tumors about equally often RP and RALP demonstrated tumour PMS (p=0.3).

Conclusion: RALP demonstrated a highly statistically significant lower rate of PSAR in the first 100 patients undergoing robotic assisted approach compared to RP. Despite the encouraging result long term follow up in homogeneous patients groups is needed for demonstrating any potential advantage of PALP in preference to RP.

 

               

AD Seyer-Hansen, S Skou, M Borre, T Lynnerup, KV Pedersen

Dept of Urology, Aarhus University Hospital, Skejby, Denmark

bayped@post8.tele.dk

 

Aim: Postoperative morbidity after radical prostatectomy have been claimed to be less after robotic access (ROP) than after an open procedure (RRP). As shown in our institution, postoperative incontinence was less after ROP (1). As ROP patients were younger and more slim, selection criterias might explain part of the difference. In the present study pre-, per- and postoperative variables were tested against the rate of incontinence.

Material: In total 133 patients were operated on during 2007, - 40% with ROP and 60% with RRP.T category, PSA, Gleason score, volume, nervesparing technique or not and surgeons experience were registered from the departments prostate cancer database. The reported incontinence rate is correlated to each of these variables to describe selective differences when choosing ROP or RRP.

Results: Total continence was reached for 88% and 72% after ROP resp. RRP after one year. Patients who were major incontinent had a leakage of 177 grams/24 hours (16-920) in the RRP group and 26 grams/24 hours (24-28) in the ROP group. Patients chosen for ROP had less tumour load and better short time biochemical oncological outcome. Nervesparing technique was used equally. ROP was performed by one experienced surgeon in contrast to RRP which was performed by several surgeons with different experience.

Conclusion: The shown benefit in morbidity favorable for ROP could be explained as a difference in selection criterias.

Ref: Seyer-Hansen AD, Hvistendahl GM, Graugaard-Jensen C, Pedersen KV, Skou S. Urinary continence after radical prostatectomy – influence by the surgical method. Submitted for NUF2009, nurse section.

 

               

HO Beisland¹, E Servoll¹, L Vlatkovic², T Sæter¹, G Waaler¹

¹Section of Urology, Sørlandet Hospital, Arendal, and ²Department of Pathology, Norwegian Radium Hospital, Oslo

hans.olav.beisland@sshf.no

 

Aim: To present the mortality rate after retropubic radical prostatectomy at a Norwegian county hospital.

Material and methods: The material consists of 151 men operated in the period October 1985 – June 2006. Median age was 61 years (range 44-72). The observation time ranges 276 – 14 months (median 80). Postoperatively the patients have been seen regularly. The hospital files were reviewed in November 2008 to collect data for this study. The histological specimens have recently been reinvestigated with regard to Gleason score an tertiary Gleason pattern by an experienced uropathologist.

Results and discussion: There is no 30-days mortality. 22 patients have died in the follow up period, six from prostate cancer (3.9%) 60-194 months postoperatively and 16 patients from other reasons (10.5%) after 14-230 months. The six patients who died from prostate cancer had all a high Gleason score. Among the 16 patients who died from other reasons, a clinical relapse occurred in seven and they had a rather high Gleason score or high-graded tertiary Gleason. It is therefore not to exclude that the prostate cancer may have been a part of the cause of their death. If these seven patients are added to the six who really died from prostate cancer, the total cancer specific mortality will increase to 8.6%.

Conclusions: The mortality rate over a period of 23 years is acceptable. It is possible to perform safe prostate cancer surgery at county hospitals.

 

               

E Servoll¹, L Vlatkovic², T Sæter¹, G Waaler¹, HO Beisland¹

¹SørlandetHospital, Arendal and ²The Norwegian Radium Hospital, Oslo, Norway

einar.servoll@sshf.no

 

Aim: The Gleason score consists of a primary and a secondary grade. However a tertiary pattern has been found in tumours. In this study we examined the impact of tertiary Gleasonon biochemical relapse rate in patients treated with RRP.

Material and methods: Between 1985 and 2005, 151 men underwent RRP at Sørlandet County Hospital, Arendal. None of the patients had preoperative radiation or androgen deprivation therapy. Clinical records were reviewed to determine patient’s characteristics and evidence of biochemical recurrence (PSA ≥0.2 ng/ml).The microscopic examination of the RRP specimens and Gleason grading was reassessed retrospectively by a single uropathologist (LV), without the knowledge of clinical outcome. Kaplan-Meier plots and Cox proportional hazards regression were used in statistical analyses.

Results and discussion: 35 patients (23.6%) had a tertiary Gleason grade 4 or 5. Biochemical relapse was observed in 67 patients (45.3%). 26 patients (74.3%) with a tertiary Gleason had PSA relapse. In analyses controlling for preoperative PSA and pathological T-stage, tertiary Gleason remained anindependent predictor of biochemical failure (p= 0.012).

Conclusion: Tertiary Gleason is a predictor of biochemical relapse in patients operated with RRP.

M Mortensen¹, BP Ulhøi², M Borre¹

Department of Urology¹ and Pathology², Aarhus University Hospital, Denmark

martinmortensen@hotmail.com

 

Aim: To evaluate surgical margin status and disease free survival rates in pT3 prostate cancer patients undergoing radical prostatectomy (RP) at our institution.

Patients and materials: Data concerning 535 RP patients has prospectively been collected for “the Aarhus PC-project”. Median follow-up was 48 (12-141) months. Recurrence of serum PSA defined as > 0.2 ng/mL.

Results: The pT-classification demonstrates 162 (30 %) cases of either extra capsular tumour extension (pT3a; n=104) or involvement of the vesicular seminalis (pT3b; n=58).Totally 147 (28 %) specimens had tumour positive margins, of which 104 (71%) had pT3 origin (p<0.001). The disease free survival was in highly statistically significant favour of patients suffering from localized disease (pT2). The positive and negative predictive value of preoperative prediction of recurrence by combining the D’Amico risk group stratification and the fraction of tumour positive biopsies was 0.82 and 0.41 respectively.

Conclusion: Radical prostatectomized patients harbouring extra capsular (pT3) tumours have a highly significantly poorer oncological outcome than those with localized (pT2) disease. For T3 tumour patients the preoperative prediction and the choice of optimal therapy remain controversial and important future challenges.

 

               

M Højgaard¹, AA Jassem¹, N Nørgaard¹, K Andersen², KJ Mikines¹

¹Department of Urology and ²Department of Oncology, Copenhagen University Hospital Herlev, Denmark

martin@hojgaard.com

 

Introduction: Previous studies of seeds migration in prostate brachytherapy have found an increased migration of loose seeds compared to stranded seeds. In December 2006 we changed from RAPID strand (Oncura, Arlington Heights IL) to loose I-125 seeds (Bard, Covington GA) implanted using a Mick-applicator (Mick Radionuclear Instruments, Mount Vernon NY).

To compare seeds migration we studied 49 consecutive patients with complete 1 year follow-up implanted with loose seeds (LS), and 47 consecutive patients with complete 1 year follow up who had RAPID strand seeds (RS) implanted.

Methods: All patients had plain film radiographs of the prostate (AP-plane and 2 angulated) after 1 day (1 d), 30 days (30 d) and 1 year (360 d) of the seed implantation. Seeds were counted at implantation at day 0 and number of migrated seeds, prostate volume, patient age, pre-treatment PSA and Gleason score were recorded. All implants were performed by the same two surgeons.

Results: The two groups had comparable pre-operative characteristics.

 

Table 1: Population characteristics
	LS (mean (SEM))	RS (mean(SEM))
Age (years)	63.2 (6.9)	63.0 (5.6)
Prostate Size (cc)	34.3 (7.7)	36.7 (6.7)
PSA pre-treatment (ng/ml)	6.6 (3.3)	7.1 (3.4)
Gleason score	6.3 (0.9)	6.3 (0.9)

 

 

Both LS and RS seeds exhibited small, but significant migration throughout the 360 day follow up. 31 of 47 (66%) RS patients had seeds migration after 360 days, which was significantly more compared to the migration in the LS group with 20 out of 49 (41%) (p<0.01, Chi²).

The absolute amount of migrated seeds after 360 days was significantly higher in the RS group (62) compared to the LS group (32) (p<0.005).

 

 

 

 

Table 2: Seeds migration – seed loss at 1, 30 and 360 days
	Total Seeds	Loss 1d	Loss 30d	Loss 360d
LS	2842	12 (0.4%)*	26 (0.9%)*	32 (1.1%)*§
RS	3171	5 (0.2%)?	35 (1.1%)?	62 (2.0%)??
LS group:* p<0.006 compared to seeds implanted at day 0    § p=0.013 compared to seeds at day 30 RS group: ? p<0.02 compared to seeds implanted at day 0     ? p<0.001 compared to seeds at day 30

 

Conclusions: Small but significant seeds migration occurs with both LS and RS during the entire first year. Loose strand seeds exhibit less migration, compared to Rapid Strand seeds. Whether this decreases the risk of PSA-failure requires further studies.

 

               

SD Fosså on behalf of participants in SPCG-7/SFUO-3

OsloUniversity Hospital, The Norwegian Radium Hospital, Oslo, Norway

sdf@radiumhospitalet.no

 

Aim: This phase III trial compares the efficacy of radiotherapy + continuous hormone treatment (RT + HT) compared to HT alone in locally advanced or high-risk localized prostate cancer.

Methods: Between 1996 and 2002, patients with locally advanced or histologically high-risk localized prostate cancer were randomized to RT + HT (N: 439) or HT (N: 436) with cancer-specific mortality as primary end-point. HT consisted of 3 months of total androgen blockade followed by continuous treatment with flutamide. Mortality and side-effects were evaluated in February 2008.

Results: After a median follow-up of 7.6 years 79 men in the HT and 37 men in the Rt + HT group had died of prostate cancer, the cumulative prostate cancer-specific mortality at 10 years being 23.9% and 11.9% respectively. The comparable rates for overall mortality were 39.4% and 29.6% respectively. Age at diagnosis (≤75 years) and initial PSA (≤70 µg/l) did not influence on the superiority in the RT + HT group. After 5 years the rates of urinary, rectal and sexual problems were slightly higher in the RT + HT than in the HT group.

Conclusion: In patients with locally advanced or high-risk localized prostate cancer the addition of RT to HT doubles cancer-specific survival and substantially reduces overall mortality, with an acceptable profile of long-term treatment-induced morbidity. These findings justify that RT + HT should become standard treatment for these patients.

 

               

P Iversen¹, D McLeod², M Wirth³, W See⁴, T Morris⁵

¹Department of Urology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; ²Walter Reed Army Medical Center, Washington, DC, USA; ³Technical University of Dresden, Dresden, Germany; ⁴Medical College of Wisconsin, Milwaukee, Wisconsin, USA; ⁵AstraZeneca, Alderley Park, Macclesfield, UK

piv@rh.regionh.dk

 

Aim: The Early Prostate Cancer program is the largest hormonal therapy trial ever conducted in men with localised or locally advanced prostate cancer. The aim of the program is to evaluate the benefits of bicalutamide 150 mg/day when added to standard care (prostatectomy, radiotherapy, or watchful waiting). We now report data from the 4^th and final analysis of the program (median 9.7 years’ follow-up).

Materials and methods: The program consists of 3 prospective, placebo-controlled trials, and includes 8113 men with T1-4, M0, any N prostate cancer. Primary endpoints were objective progression-free survival (PFS) and overall survival (OS).

Results and discussion: Across the whole program, 31% of patients have died of any cause; 6.3% of patients with localised disease died of prostate cancer compared with 16.2% of those with locally advanced disease. Bicalutamide continues to significantly improve PFS (HR 0.85; p<0.00001), while no significant difference in OS was seen (HR 1.01; p=0.76). Overall results are consistent with previous analyses, with PFS improvements driven by locally advanced subgroups and the previously observed trends regarding OS in watchful waiting patients continuing to be seen.

Conclusions: In localised disease, the risks of hormonal therapy with bicalutamide outweigh the benefits in delaying progression. However, in locally advanced disease there are benefits: conversion to metastatic disease can be delayed and survival can be improved in certain groups.

 

               

P Iversen¹, TK Olesen², B-E Persson³

¹Rigshospitalet, Copenhagen, Denmark; 2Ferring Pharmaceuticals Inc., Parsippany, United States, ³Ferring Pharmaceuticals, Saint-Prex, Switzerland

pigi@dadlnet.dk 

 

Aim: To compare the efficacy and safety of degarelix, a new GnRH receptor blocker, with leuprolide in a 12-month, open-label study in patients with prostate cancer.

Materials and methods: 610 patients with adenocarcinoma of the prostate for whom androgen deprivation therapy was indicated, were randomised to: degarelix starting dose 240 mg s.c. for 1 month followed by monthly maintenance doses of 80 mg s.c. (n=207), 160 mg s.c. (n=202) or monthly i.m. injections of leuprolide depot 7.5 mg (n=201). Here we report data for degarelix 240/80 mg (approved dose) vs. leuprolide.

Results and discussion: Baseline characteristics were similar across groups (mean age 72 yrs; median T 3.93 ng/mL; median prostate-specific antigen [PSA] 19.0 ng/mL). LH and FSH levels decreased rapidly during degarelix treatment; at study end, mean FSH had decreased from baseline by 88.5% and 54.8%, in the degarelix and leuprolide groups, respectively. Degarelix demonstrated non-inferiority vs. leuprolide at achieving the primary endpoint (serum T levels ≤0.5 ng/mL from Day 28 through Day 364). Safety profiles were mainly related to hormonal effects of treatment and the underlying disease.

 

	Degarelix 240/80 mg (n=207)	Leuprolide 7.5 mg (n=201)
Patients with testosterone ≤0.5 ng/mL, %
Day 3	96.1	0
Day 14	100.0	18.2
Days 28-364	97.2	96.4
Patients with testosterone surge, n (%)	0	80.1
Patients with testosterone escape,a n (%)	2.4	3.5
Median reduction in PSA from baseline, %
Day 14	64*	18
Day 28	85*	68

 

^aTestosterone (T) escape = at least one T value >0.5 ng/mL between Day 28 and Day 364. *p<0.001 vs leuprolide

 

Conclusion: Degarelix reduces serum FSH, LH, testosterone and PSA levels faster than leuprolide; without a testosterone surge. Testosterone was reduced to very low levels and degarelix was at least as effective as leuprolide in maintaining serum T levels ≤0.5 ng/mL for the duration of the study.

 

               

G Piotrowicz, H Zielinski, R Jedynak

Urology Department, Military Institute of Medicine, Warsaw, Poland

gppiotr@poczta.onet.pl

 

Aim: The aim of the study is to evaluate the results of photoselective vaporization of the prostate (PVP) with 120W Greenlight laser in the treatment of patients with BPH on anticoagulants.

Material and methods: 77 patients underwent PVP in our department from 2006 to 2008. 65 patients were on anticoagulants.

We evaluated objective and subjective parameters before and 1, 6 and 12 months after PVP. Duration of the procedure, time of catheterization and hospitalization as well as morphological and biochemical parameters and intra – and postoperative complications were assessed.

Results: The mean catheterization time was 18.5 hours. The mean hospitalization time after PVP was 1.4 days. The mean maximum urinary flow rate improved from 9.8 before to 21.8, 22.8 and 21.9 ml/s; PVR decreased from 118.2 to 35.6, 32.9 and 34.1 ml; IPSS decreased from 24.7 to 11.2, 7.3 and 7.1; QoL score decreased from 4.85 to 2.3, 1.74 and 1.71 at 1, 6 and 12 months, respectively.

There was no major complication during PVP. No significant change in morphological and biochemical parameters was observed and no blood transfusion was necessary. Main postoperative complications included mild transient dysuria and hematuria. 2 patients required recatheterization due to urine retention. 10 out of 26 sexually active patients had retrograde ejaculation. 1 patient required re-TURP and 2 had urethral stricture.

Conclusion: PVP with 120W Greenlight laser appears to be safe and effective method of treatment for patients with BPH on anticoagulants.

M Højgaard¹, L Fahrenkrug¹, J Schou²

¹Department of Urology, Herlev Hospital, Herlev, ²Urologisk Klinik, Privathospitalet Hamlet, Søborg, Denmark

marhoj01@heh.regionh.dk

 

Introduction: Transurethral resection of the prostate (TUR-P) in saline can potentially reduce the risk of TUR-syndrome, increase patient safety, shorten current path and reduce operating time. The newest addition to the bipolar systems is a button electrode for plasma vaporization (BEPV), allowing for vaporization of the prostate. The aim of this study was to investigate safety and short term outcome of patients operated for benign prostatic hyperplasia with the BEPV.

Method:94 patients at 2 urological centres underwent TUR-P with the Olympus button electrode WA22557C in the TURis system (UES-40 Surgmaster, Olympus, Hamburg, Germany) in 2008. The operation decision was made by board certified urologists (BCU) in accordance with current Danish guidelines. The patients were operated by 5 BCUs. Maximum flow(Q_max), residual urine(V_res), prostate volume (P_vol) and Danish Prostate Symptom Score (DAN-PSS) were registered preoperatively. Q_max, V_res , DAN-PSS and complications were registered 3 months postoperatively.

Results: 12 patients were operated using both BEPV and loop electrode and were excluded from analysis, as were 3 patients with prostate cancer, leaving 79 patients for analysis.

One patient required blood transfusions postoperatively, 1 patient had febrile urinary tract infection and 2 patients required cystoscopic re-intervention to obtain hemostasis and clot evacuation. No TUR syndromes were registered.

At 3 months 6 patients had, or had been scheduled for, surgery for bladder neck strictures, 1 was re-operated for residual adenoma and 1 patient complained of stress incontinence.

 

Table 1. Population characteristics
Age, mean	66 years (39-89)
Prostate volume, mean	53ml (16-168)
Operating time, mean	50 minutes (17-130)

 

 

Table 2. Symptom score and voiding parameter changes
	Pre-operatively	3 months follow up	% change
Qmax mean	8.3 ml/s (2.0-17)	13.3 ml/s (3.7-32.6)	+ 60%*
Vres mean	126 ml (0-491)	61 ml (0-320)	-52%*
DAN-PSS-score mean	32 (1-61)	5.9 (0-25)	-82%*
* p<0,01 Wilcoxon Signed Rank Test

 

 

Conclusions: The BEPV provides significant improvement in voiding parameters and symptom score with few postoperative bleedings and an acceptable amount of short term complications.

Increases in Q_max were lower than previous studies on conventional TUR-P and photoselective vaporization of the prostate, whilst improvements in symptom score were comparable.
Large scale, randomized studies are required to establish long term outcome in aspects of voiding and safety in comparison with other surgical modalities for BPH-treatment.

 

               

M Cek¹, P Tenke², K Naber³, KV Pedersen⁴, TEB Johansen⁴ on behalf of the GPIU*-investigators and the board of ESIU

¹Urology Department, Taksim Teaching Hospital, Istanbul, Turkey^{, 2}Urology Department, Jahn Ferenc South-Pest Hospital, Budapest, Hungary, ³Karl-Bickleder-Str. 44c D-94315 Straubing, Germany, ⁴Urology Dept., Århus University Hospital, Århus, Denmark

*Global Prevalence Study on Infections in Urology

cekmd@doruk.net.tr

 

Aim of investigation: The role of indwelling urinary catheter and preoperative administration of antibiotics in the development of nosocomial urinary tract infections (NAUTI) in a subset of patients undergoing TURP was studied.

Subjects and methods: 129 of the investigators registered for GPIU (2006/7) completed an additional questionnaire for patients who underwent TURP. The presence and duration of a catheter on admission, replacement within the last week, recent prescription of antibiotics before TURP and development of a NAUTI after TURP were addressed and analysed as possible risk factors for the development of NAUTI after TURP.

Results and discussion: 599 patients with evaluable data were included.17.3% of patients with indwelling catheters developed UTI post-TURP compared to 6.7% of patients without catheter (p=0,001). 13.2%who received antibiotics before and until TURP developed UTI compared to 7.8% without antibiotics (p=0,001). Patients without catheters on admission or had it for 7 days or less, 7.9% developed NAUTI compared to 19.1% for those who had catheters for more than a week (p=0.001).Of 91 patients who had the catheter replaced within the week preoperatively 18.7% developed UTI compared to 36 out of 364 (9.9%) without replacement (p=0.001).

Conclusions: Urinary catheters on admission, treatment with antibiotics immediately before TURP and recent replacement of urinary catheters are associated with the development of NAUTI’s in such patients.

 

               

A Lidgren, A Bergh, K Grankvist, G Lindh, B Ljungberg

Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden

borje.ljungberg@urologi.umu.se

 

Aim: Angiogenesis plays a central role in tumor growth. The hypoxia inducible factor (HIF-1a) is a regulated subunit of HIF-1, a key factor that carries fundamental features in angiogenesis and tumour progression. Renal cell carcinoma (RCC) is rich vascularised with a variable clinical outcome, having specific genetic alterations in different RCC types. We investigated HIF-1α mRNA and protein expression in relation to RCC type and clinicopathological variables.

Methods: Quantitative analysis of HIF-1a mRNA expression in 202 patients including 168 clear cell (cRCC), 23 papillary (pRCC) and 11 chromophobe RCCs. Also, 49 samples from corresponding kidney cortex were analysed. Comparative analysis of HIF-1α protein expression was performed by immunohistochemistry using a tissue micro array.

Results and discussion: HIF-1a mRNA levels were significantly lower in cRCC than in pRCC (p=0.001) and kidney cortex (p=<0.000). In cRCC, HIF-1α mRNA correlated to gender and age. For pRCC there was no correlation between HIF-1a mRNA and stage, grade, age, tumour size or gender. HIF-1a mRNA expression was inversely related to HIF-1a protein levels in pRCC (p=0.041) and nonsignificantly in cRCC (p=0.075).

Conclusion: HIF-1a mRNA levels were significantly lower in cRCC than in kidney cortex and other RCC types. High HIF-1a protein expression appeared to suppress HIF-1a mRNA expression, distressing the HIF-1 pathway in RCC. Further studies of the function of HIF-1 in the different RCC types are encouraged.

 

 

               

L Lund*, M Jønler, LJ Petersen, J Abrahamsen

Viborg, Denmark

dr.ll@dadlnet.dk

 

Aim: We present the results after laparoscopic assisted cryoablation for renal carcinoma.

Material and methods: Renal cryoablation was performed in 27 cases in 24 patients with renal carcinoma. Pre-operative work-up included blood samples, GFR, scintigram, ultrasound guided core biopsy from tumor, and CT/MR scanning of chest and abdomen. Follow-up involved blood samples, evaluation of renal function by GFR, and CT or MRI imaging at 3 months, 6 months, 12 months, 18 months postoperative and then annually. A cryo-lesion biopsy was performed if there was an enhancement in the treated area. All data were prospectively accrued.

Results: We included 19 men and 5 women. Mean age was 71 years (range 49-86 years). Three patients had only one kidney. The mean follow-up time was 18 months (3-36 months). Mean tumor size was 3.5 cm (1.6-6.5 cm). Median ASA score was III. Mean operating time 187 min (155−210 min) with a mean hospital stay of 2 days (1-3 days). There was no change in creatinin or cystatine-C after cryo-ablation. The GFR was within normal range after treatment in all but patients with one kidney or one functional kidney where the function declined on average with 10%. The treatment of larger tumors was found to affect the split renogram. Overall, 1 patient developed local recurrence and 1 patient developed a new tumor in the previously treated kidney. One patient developed metastatic disease. There were 4 cancer deaths.

Conclusions: Laparoscopic assisted renal cryoablation is an effective oncologic treatment for renal carcinoma in selected patients. Renal function is well preserved in large majority of the patients:

 

               

SJ Oddsson^1,4, S Hardarson^2, V Petursdottir^2, E Jonsson^3,4, H Vidarsdottir1, GV Einarsson^3, T Gudbjartsson^1,4

Departments of ¹Cardiothoracic surgery, ²Pathology and ³Urology, Landspitali University, ⁴Faculty of Medicine, University of Iceland, Reykjavik Iceland

saemiodds@hotmail.com

 

Objective: Metastases are present in 20-30% of patients diagnosed with RCC. Pulmonary metastases are most common and survival of these patients is usually dismal. Recently, pulmonary metastasectomy has been shown to significantly improve survival in a subgroup of RCC patients, especially those with a solitary metastasis. We studied synchronous pulmonary metastases in patients diagnosed with RCC and evaluated how many of them could theoretically benefit from metastasectomy.

Material and methods: This is a retrospective study including all patients diagnosed alive with RCC in Iceland between 1971 and 2000. Clinical information was obtained from patient charts, histology was reviewed and tumors staged according to the TNM staging system. Synchronous metastases were defined as metastases diagnosed within 3 months after the diagnosis of RCC.

Results: Out of 701 patients, 130 had pulmonary metastases (18.5%). Fifty four of these patients had metastases confined to the lungs, 38 (79%) of them with multiple metastases, including 27 (56%) with bilateral lesions. A solitary pulmonary metastasis was detected in 10 patients (6 males, mean age 63 years). All of these 10 patients had a resectable kidney tumor and were in good health; however, only one of them underwent metastasectomy.

Conclusion: One out of five patients has synchronous pulmonary metastasis at the diagnosis of RCC. In every other case these metastases are confined to the lungs and many of them are solitary. If solitary metastases are used as criteria for resection, between 7-8 % of RCC patients with synchronous pulmary metastasis could potentially be candidates for metastasectomy.

 

               

HB Palsdottir^1,4, S Hardarson², V Petursdottir², A Jonsson^1,4, E Jonsson^1,4, GV Einarsson¹, T Gudbjartsson^1,3

¹Departments of Urology, ²Pathology and ³Surgery, Landspitali University Hospital, ⁴Faculty of Medicine, University of Iceland, Reykjavik, Iceland

hbp1@hi.is

 

Introduction:Increased incidence of renal cell carcinoma (RCC) in Iceland has mainly been attributed to increase in incidental detection due to abdominal imaging of unrelated disease. However, the impact of incidental detection on survival has been debated. We studied prognostic factors of survival focusing on the effect of incidental detection on survival and incidence.

Materials and methods:A retrospective nationwide study of all living patients diagnosed with RCC in Iceland 1971-2005; 913 patients with mean age 65 years and M/F ratio 1.6. Clinical information was gathered, histology reviewed and all tumors staged according to the TNM staging system. Incidentally diagnosed RCCs were compared to symptomatic tumors and prognostic factors evaluated using Cox multivariate analysis.

Results: Incidence of RCC increased significantly during the last 5-year period for both sexes, mortality remaining unchanged. Out of 913 patients, 255 (28%) were diagnosed incidentally, most often because of abdominal ultrasound (29.1%) or computed tomography (27.1%). Incidental detection increased from 11.1% in 1971-75 to 39.2% in 2001-5 (p<0.05). Incidentally detected tumors were 2.7cm smaller and diagnosed at a lower stage and lower tumor grades compared to symptomatic tumors. Age, M/F ratio and histology were similar in both groups. TNM stage was by far the strongest independent prognostic factor of survival, nuclear grade, age, calendar year of diagnosis and ESR also being significant. Furthermore, symptomatic RCC patients had worse survival than those that were diagnosed incidentally (HR 1.4; 95% CI 1.02-1.93; p=0.04).

Conclusion:Survival of RCC patients in Iceland has improved with increased incidence and unchanged mortality. The main reason for this improvement is a steep rise in incidental detection. Incidental detection affects survival favorably, a survival benefit greater than can be explained by lower stage and grade when compared to patients diagnosed with symptoms.

 

               

J Skoogh^1,5, G Steineck^1,2, A Wallin³, M Gatz⁴, B Johansson⁵

¹Clinical Cancer Epidemiology, The Sahlgrenska Academy, Gothenburg, Sweden, ²Clinical Cancer Epidemiology/Karolinska Institute, Stockholm, Sweden, ³Institute of Neuroscience and Physiology, The Sahlgrenska Academy, Gothenburg, Sweden, ⁴Department of Psychology, University of Southern California, Los Angeles, United States, /Karolinska Institute, Stockholm, Sweden, ⁵Department of Psychology, Gothenburg, Sweden

johanna.skoogh@oncology.gu.se

 

Aim: To construct a questionnaire measuring experienced chemotherapy-induced effects on cognitive function among testicular cancer patients using questions about every-day behaviour.

Method: During an 18-month qualitative phase we constructed a study-specific questionnaire based on interviews with 20 cancer patients who experienced chemotherapy-induced cognitive decline. Using an open interview we deliberately applied an unbiased approach, asking about specific behaviour without references to domains of cognitive function. Patients reported a variety of problems such as difficulties finding the right words, being dependent on notes for memory and feeling lack of energy. When phrasing questions in our questionnaire we tried to use the wordings given by the patients as exactly as possible. The final questionnaire included 295 questions that were tested in a pilot study. After receiving 33 of 36 questionnaires we proceeded to the main study. The procedures followed the established routines and the format developed at our division of Clinical Cancer Epidemiology.

Results: Among the 1175 eligible testicular cancer patients, 960 (82 percent) answered the questionnaire. Before analysing data an expert panel categorized the questions according to a judgement of which cognitive domain each of the questions covered. We identified 59 questions believed to measure mainly one specific cognitive domain: 6 attention, 26 memory, 5 visuospatial ability, 7 language, 2 speed and 13 questions for executive function.

Conclusion: A questionnaire, designed to measure cognitive function based on questions about behaviour in everyday life, was found to provide valuable information in a population of testicular-cancer survivors.

 

               

T Nielsen, JB Jensen

Urology Department, Regionshospital Holstebro, Denmark

tommyniel@gmail.com

 

Aim: To investigate 1) the importance of stone size and location in relation to ESWL of renal stones 2) whether stone size or location influence the risk of acute treatment with an uretral stent (JJ-stent) after ESWL.

Material and methods: Between 1999 and 2007 a total of 461 patients with 589 renal stones were treated with ESWL. A commercial company (MLS Medical A/S) assisted by the treating urologist conducted the treatment using a Storz Modulih SLK. Each stone was retrospectively arranged according to size, location, number of ESWL treatments and auxiliary procedures.

Results: The overall success rate after 1st ESWL was 69% and this increased to 93% after one or more re-treatments.

A correlation analyses between stone size and overall success rate demonstrated a significant decrease in success rate as stone size increased (r = -0.2, p<0,01).

With the exception of upper calyx after re-ESWL (p < 0,05), the difference in success rate according to stone location did not prove significant.

A total of 17 patients (2,9%) needed treatment with JJ-stent after ESWL. No significant difference was observed between stone size or location and the risk of being treated with a JJ-stent after ESWL.

Conclusion: A success rate of more then 90% can be obtained with repeated ESWL of renal stones up to 30 mm, but an inverse relation between stone size and success rate was observed. Patients who did not require treatment with JJ-stents prior to ESWL does rarely need JJ-stents after ESWL.

 

R Källström¹, H Hjertberg², J Svanvik³

Dept. of Urology, ¹University Hospital Linköping and ²Vrinnevi Hospital Norrköping, ³Dept of Surgery, University Hospital Linköping, Sweden

reidar.kallstrom@lio.se 

 

Aim: Learning outside the operating room provides practice in a controlled fashion with increasing levels of difficulty whenever there is time. Training in the basic skills of TURP has a long learning curve (70-90 procedures). The purpose of this study was to construct and to examine the face, content and construct validity of a full procedure, virtual reality TUR-P simulator.

Materials and methods: The construction of the simulator (PelvicVision) was based on a face validity study (17 urologists) and a content validity study (9 urologists). The simulator consists of a resectoscope connected to a robotic arm with haptic feedback and foot pedals connected to a personal computer; the picture of the prostatic urethra, the bladder and the resectoscope tip is presented. The flow of irrigation fluid, the amount of bleeding and the corresponding blood fog is calculated. The movements, resection volumes, use of current, etc, is measured. Data from the simulation were analyzed after performing 6 (11 students) and 3 (9 urologists) procedures with different levels of difficulty.

Results and discussion: The students showed a positive learning curve. The urologists were more effective, active and careful. It is still necessary to evaluate the effect of simulator training in the clinical situation.

Conclusion: There is proof of face, content and construct validity for this simulator for training in TURP. The simulator could be used in the early training of urology residents without risk of negative outcome.

Key words: transurethral resection of prostate; computer simulation; medical education; task performance and analysis.

 

               

L Lund¹, A Dubrowski², DS Herrell³, K Kijvikai⁴, H Carnahan⁵

¹Viborg, Denmark, ²Toronto, On, Canada, ³Nashville, TN, USA, ⁴Bangkok, Thailand, ⁵Toronto, ON, Canada

dr.ll@dadlnet.dk

 

Aim: The widespread use of laparoscopy has created a growing demand for uniformity in education and curriculum. Urologic training in minimal invasive surgery should be based on theory and principles that would lead to universal guidelines. To begin the dialogue necessary to develop a unified educational approach, and in an effort to understand the perceived needs of trainees at an international level we evaluated the current exposure to laparoscopic training programs and simulation at 11 institutions in three countries.

Material and methods: A 23 item, e-mail based questionnaire was sent to 64 residents in Denmark, Thailand and United States. Areas evaluated included: age. year of training, type of hospital, exposure to low and high fidelity training, simulator training, certification and exposure to performing laparoscopy.

Results: There was a 64% (43/67) response rate to the survey. The participants came from Denmark (73%), Thailand (5%) and t United States (22%). The majority of participants were between the ages 30-34 years old. There were many differences between the responses from the 3 countries such as type of hospital; experience with real operations; experience with simulation based courses; and the desire for certification in laparoscopic procedures. Although the exposure to laparoscopic urological surgery is highest in USA we found a difference between the countries in offering laparoscopy courses to trainees (Thailand (100%), Denmark (96%), USA (39%). However, a desire for exposure to simulation based courses was shared by all respondents, regardless of country.

Conclusions: Although a small sample size, thus some caution must be used when interpreting the findings. However, the present data are valuable as a helping guide for further investigation into the need for international guidelines in training programs and development of education and simulation in urologic surgery for the next generation of minimally invasive surgeons.

 

               

S Göthe, R Peeker

Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden

sofia.gothe@gmail.com 

 

Background: There is always a potential risk of injury the urinary tract during surgery in the lower abdomen and the lesser pelvis. Injuries to the bladder and ureters are often associated with significant morbidity such as infections and/or loss of renal function.

Aim: The aim was to investigate the occurrence of iatrogenic injuries to the bladder and the ureters, during which procedures, diagnostics, mode of reconstruction and final outcome.

Method: All patients in our hospital diagnosed with an iatrogenic injury to the urinary tract were studied between 1^st January 2000 to the end of June 2007 (7.5 years). Data collected included type of surgery, type of injury, measures to establish the diagnosis and when this was done, how and when the reconstruction took place and who performed it.

Result: 166 patients were found and 160 were selected. Gynaecological procedures represented the majority of the underlying cause, hysterectomy being the commonest. The bladder and ureters were most commonly injured through lacerations. For the vast majority of these patients, the result after repair was fully satisfactory. However, quite many suffered from infections preoperatively and a few patients experienced some degree of deterioration of renal function.

Conclusions: It is imperative that these patients are treated by surgeons/urologists in possession with adequate knowledge and skill. The outcome for these patients is satisfactory in most cases, especially when the injury is primarily recognised and reconstructed. The road to healing can however be utterly cumbersome and that is why these patients must not be neglected. There is often a doctor’s delay when these patients seek medical attention for their symptoms. It is therefore of paramount importance that unexpected symptoms after pelvic surgery are thoroughly investigated in order to rule out complications.

 

               

J Sønksen¹, D Löchner-Ernst², N Brackett³, D Ohl⁴, C Lynne³

¹Dept of Urology, Herlev Hospital, University of Copenhagen, Denmark, ²BG-Unfallklinik Murnau, Murnau, Germany, ³The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida, USA, ⁴Dept of Urology, University of Michigan, Ann Arbor, Michigan, USA

sonksen@mail.dk 

 

Aim: An ejaculation and impairment of semen quality are commonly found in men after spinal cord injury (SCI). Over the past several decades, clinical treatments and assisted reproductive techniques have been developed allowing SCI men to father children. However, only very few home pregnancies have been reported in the literature. The aim of this study is to present the last 20 years’ experience from penile vibratory stimulation (PVS) and vaginal self-insemination at home in SCI men and their partners. The data originate from two European and two American centers.

Material and methods: Men with SCI and their healthy female partners seeking treatment for infertility were evaluated for this study. Antegrade ejaculation was induced by PVS and basic semen analysis was performed (WHO criteria). Only men who had motile sperm in the ejaculate were included. The main outcome measures were total motile sperm count, time to pregnancies, numbers of pregnancies and miscarriages.

Results: A total of 169 SCI men (median age 32 yrs, range 22-44) and their partners (median age 29 yrs, range 19-36) met the inclusion criteria and were included in the study. The median total motile sperm count was 31 million (range 1-426). Overall, 73 of the 169 couples (43%) achieved 99 pregnancies with delivery of 90 healthy babies (88 singletons and 1 pair of twins). The median time to pregnancy was 1.2 years (range 0.1-8.2). A total of 10 miscarriages in 9 couples were noted

Conclusion: Based on the largest study of its kind to date, it is concluded that PVS combined with vaginal self-insemination may be performed as a viable, inexpensive option for assisted conception in couples in whom the SCI male partner has adequate semen parameters and the female partner is healthy.

 

               

V Karadzic, L Malmberg

Department of Urology, Clinical Sciences, Lund, Sweden

violetta.karadzic@skane.se

 

Aim of investigation: Injection therapy with Botulinum toxin A (BTX-A) is increasingly used in patients with neurogenic detrusor overactivity (NDO) who fail conservative treatment. We evaluated the results of repeated therapy.

Subjects and methods: Patients with NDO who subjectively had severe urinary incontinence and/or urgency in spite of conservative treatment were included. 19 men and 10 women were screened for treatment with 300 U of BTX-A (Botox®). Causes of neurogenic dysfunction were: Spinal cord injury, MS, cerebrovascular lesion or Parkinson‘s disease.

Results and discussion: Mean number of wet pads per week decreased from 17 before treatment to 7 after. Number of incontinence-free days per week increased from 3 to 5. Eight out of 11 patients who had indwelling catheter due to severe symptoms became catheter-free. Disease specific quality of life significantly increased from I-Qol-score 47 to 70. A similar increment was noticed after re-injection. Median time between treatments was 320 days. No serious adverse events were reported. Two patients with high spinal cord injuries and marked autonomic dysreflexia reported weakness in the arms and shoulders.

Conclusions: Repeated detrusor injection treatment with BTX-A seems to be very effective in reducing symptoms of neurogenic detrusor overactivity and, thereby, increasing patient’s quality of life. The rate of adverse events is low. Patients with high spinal cord lesions and autonomic dysreflexia should be carefully advised.

 

               

LH Olsen, I Grothe, YF Rawashdeh, TM Jørgensen

Paediatric Urology, Dept. Urology, Aarhus University Hospital Skejby, Aarhus, Denmark

h-olsen@dadlnet.dk

 

Aim of the study: The voiding of healthy newborn boys shortly after term is dominated by dyscoordinated flow patterns and continues to do so during the first year of life. This study addresses the flow patterns of premature boys.

Subjects and Methods: The parents of 29 otherwise healthy premature males accepted to let their child participate in the study. Flow measurements were carried out using an ultrasound flow probe device during a 4-hour observation period. Flow patterns were assessed according to the definitions of the ICCS. Data of 25 boys (median gestational age/weight at birth: 31.3 weeks/1590 g) with 98 micturitions where applicable for analysis. Results are reported as median (range).

Results: On examination median age was 10 (3-42) days. Flow patterns were bell-shaped in 48%, interrupted in 44%, staccato in 6% and plateau in 2%. In nine of the 47 bell-shaped curves (19%) some fluctuations occurred though not fulfilling the criteria of staccato. None of the premies with more than one recorded micturition had bell-shaped curves only. The number of coordinated flows was not correlated to the age (r² 0.016, P=0.6). Subjects voided 0.7 (0.2-3.6) times/hour with a volume of 3.9 (0.6-25.2) mL. Median Qmax was 1.0 (0.3-10.0) mL/s.

Conclusion: Male premies void with a high degree of dyscoordination, small volumes and Qmax values indicating incomplete bladder emptying. Dyscoordinated voiding seems to be part of the natural development of voiding function. This study supports the observations made in mature newborns and during infancy showing maturational voiding coordination.

 

               

I Paananen¹, P Ohtonen¹, I Perttilä², O Jonsson³, C Edlund³, P Wiklund⁴, B Ljungberg⁵, KM Jensen⁶, E Jonsson⁷, W Månsson⁸

¹Oulu University Hospital, Dept. of Urology, Oulu, Finland, ²University Hospital, Dept. of Urology, Helsinki, Finland, ³Sahlgrenska University Hospital, Dept. of Urology, Gothenburg, Sweden, ⁴Karolinska University Hospital, Dept. of Urology, Stockholm, Sweden, ⁵Umeå University Hospital, Dept. of Urology, Umeå, Sweden, ⁶Aarhus University Hospital, Dept. of Urology, Aarhus, Denmark, ⁷University Hospital, Dept. of Urology, Reykjavik, Iceland, ⁸University Hospital, Dept. of Urology, Lund, Sweden

ilkka.paananen@ppshp.fi

 

Introduction and objectives: Many techniques for orthotopic bladder substitution have been described. The definition of continence after the procedure varies, as do the continence rates reported. Few studies have focused on objective functional parameters.

Material and methods: The Collaboration Group for Reconstructive Urology within the Scandinavian Association of Urology performed a prospective comparative study in men undergoing radical cystectomy and orthotopic bladder substitution. Consecutive patients underwent enterocystometry, uroflowmetry, pad weight test, and filled in a micturition protocol 6 and 12 months postoperatively. 78 men; 66 with an ileal bladder (30 with a Studer Pouch (S), 24 with a Hautmann Pouch (H), and 12 with a T-Pouch (T)), and 12 with a detubularized right colonic bladder were studied. No attempt at nerve sparing was done at cystectomy. Patients who received adjuvant chemotherapy or developed recurrence were excluded.

Results: Enterocystometry did not differ between the groups with regard to volume and basal pressure at FS, ND and SD, except for volume at SD, which was higher in colonic than in ileal pouches (p=0.001). There was no difference in compliance. The amplitude of contractions was higher in colonic pouches than in ileal pouches at SD (p=0.042), but not at FS and ND. Free uroflowmetry showed lower voided volume, lower Qmax and higher residual urine in colonic than in ileal pouches (p=0.01, p<0.001 and 0.059, respectively).In the flow given after enterocystometry there were no differences. Pad or urinal was used during the day by all patients with a colonic pouch and by 32% of those with ileal pouch (p<0.001). Within the ileal group the figures were 19%, 41%, 56% of S, H and T, respectively. Corresponding figures for use at night were 100 %, 68%, 65%, and 89%. Pad weight test showed a median/mean daytime leakage of 16/82 ml in the colonic group and 0/4 in the ileal group (p<0.001). The figures were 0/0.05 ml, 0/11 ml, and 0/1.5 ml for the S, H and T, respectively. Corresponding figures for nocturnal leakage were 13/60 ml for the colonic group and 4/64 ml for the ileal group (NS). The figures were 7/36 ml, 0/51 ml, and 120/166 ml for the S, H and T, respectively. There was no correlation between the amplitude of contractions and urine leakage in the colonic group, nor in the ileal group. CIC was performed by no patient with colonic bladder and by 18% of those with an ileal bladder (NS). The figures were 7%, 36% and 22%, respectively, for those with S, H and T.

Conclusions: Right colonic pouches are inferior to those constructed from ileum, both at enterocystometry, uroflowmetry and clinically. The three types of ileal pouches are rather similar in these respects, although the T-pouch was associated with considerably greater nocturnal leakage. The variation within each group was large, and has not yet been explained. This warrants further studies.

 

               

HV Holm, T Talseth, A Schultz

OsloUniversity Hospital, Rikshospitalet, Department of Urology, Norway

henriette.veiby.holm@rikshospitalet.no 

 

Aim of investigation: Continent urinary diversion is an alternative to conduit in patients who need supravesical diversion because of severe benign dysfunction or malformation of the lower urinary tract. The aim of this study is to assess the result of a 19-year experience with the continent right colonic urinary reservoir, performed and followed up according to a prospective protocol.

Material and methods: Since 1989 all patients who received a continent right colonic detubularized urinary reservoir were included in the study. Parameters evaluated include functional outcomes and complications. 91 patients are included in the study, 68 females and 26 males, mean age at surgery 33.7 years (14 – 69). The mean follow-up was 115 months (13 – 227 months).

Results: There was no mortality related to the procedure. 75 patients (82%) experienced one or more complications, ranging from vitamin B₁₂ deficiency (12%) and urinary tract infections (16%) to surgery. In 56 patients (62%) surgery was undertaken because of leakage (18%), catheterization difficulties (14%), perforation of the reservoir (13%), and ureteral stenosis (11%).

Conclusion: A continent right colonic urinary reservoir is a good alternative for urinary diversion. The rate of complications requiring surgery was relatively high, but the majority was minor interventions.

 

               

R Hofmann, P Olbert, A Hegele, A Schrader

Dept. of Urology and Pediatric Urology, Philipps University Marburg, Germany

Rainer.Hofmann@med.uni-marburg.de 

 

Aim: Urinary diversion following cystectomy can be performed either by standard ileal conduit, ileal- oder ileocecal neobladder or a pouch with an efferent limb to the skin.

The principle of the Indiana pouch with a tapered terminal ileum and the ileocecal valve was used for a modified ileocecal pouch with an umbilical stoma.

Material and methods: after cystectomy a pouch was formed of 30cm ileum and 8-10cm ascending colon. Detubularization and reconfirmation to a pouch was performed. The ureters were implanted in a spatulated end-side fashion preferably into the colon. The efferent limb was constructed out of 5-7 cm terminal ileum. The efferent limb was stapled and tapered over a 12 F red rubber catheter. Inverting non-resorbable Lembert sutures were used to secure and additionally narrow the ileum. The ileocecal valve was also inverted with non-resorbable Lembert sutures. After rotating the pouch 180^o counter clockwise the efferent limb reached to the umbilicus.

84 patients were operated. 64 patients (51 females,13 males) had muscle invasive urothelial cancer, 12 were converted from an ileal conduit or an ureteral stoma and 8 patients had non malignant disease (post irradiation, contracted bladder?.).

9 patients had their stoma implanted into the right lower abdominal quadrant, 75 had an umbilical stoma. Median follow-up was 5 years.

Results: 82/84 patients were completely dry during catheter intervals. Patients had to catheterize the pouch 0.8 x per night to stay dry. Daytime interval between cath was 4.2 h, night time 4.6 h.

Specific complications included revision of the umbilicus in 6 patients due to catheterisation difficulties, leakage of the pouch in 2 pat., and ureteral stenosis in 5 patients. Functional capacity of the pouch was 550 ml (320-740 ml), cystometric capacity at 10 cm H₂O 490 ml (300-640 ml). Maximum pressure was 27 cm H₂O and median pressure 18 cm H₂O, maximum pressure in the efferent limb was 72 cm H₂0 and median pressure 45 cm H₂O.

Conclusions: The principle of an efferent limb according to the Indiana pouch was used. The ileocecal valve, a tapered efferent ileum, an inverted and narrowed ICV and the isoperisaltic bowel movement in the terminal ileum all add to a continent and reliable stoma. Long durability of the catheterizable ileum, few complications with stenosis at the umbilicus-ileal anastomosis and a low pressure reservoir lead to high patient satisfaction also in the long run.

 

               

A Schultz¹, B Boye¹, O Jonsson², P Thind³, W Månsson⁴

¹Rikshospitalet, Oslo, Norway, ²Sahlgrenska University Hospital, Gøteborg, Sweden, ³Rigshospitalet, Copenhagen, Denmark, ⁴Lund University Hospital, Sweden

alexander.schultz@rikshospitalet.no

 

Aim of investigation: To evaluate whether urostomy improves quality of life in patients with disabling lower urinary tract dysfunction and the cost of surgery in terms of complications and hospital stay.

Material and methods: Fifty two consecutive patients undergoing urinary diversion were included in a prospective study. The patients completed the generic quality of life instrument WHOQOL-BREF, and a bladder/urostomy specific quality of life instrument preoperatively, and 6 and 12 months after surgery. Complications and hospital stay were registered.

Results: There was no mortality related to the surgery. The patients improved in all domains but social relationship on the generic quality of life instrument (p<0.05) and in all domains on the disease specific quality of life instrument (p<0.0005) from baseline to 12 months follow up.

The improvement was reported during the first 6 months, with no further improvement thereafter.

For the question on future perspective, improvement from 5.2 to 1.4 (1 indicating „satisfaction“ and 7 indicating „worst possible“) was seen. Hospital stay was 14 days. Early and late complications required open surgery in 12 patients (23%). Out of 41 patients who had GFR determination both preoperatively and a year after surgery, 3 had reduction in GFR of >25%.

 Conclusion: Urostomy improves both general and disease specific quality of life in patients with disabling lower urinary tract dysfunction. However, the risk of complications is not negligible.

 

               

T Davidsson¹, M Holmer¹, P-O Bendahl², S Gudjonsson¹, W Månsson¹, F Liedberg^{3 *}

¹Department of Urology and ²Department of Oncology, Lund University Hospital, Lund, ³Department of Urology, Växjö County Hospital, Växjö, Sweden

thomas.davidsson@skane.se 

 

Aim: Extended and limited lymph node dissections, performed during radical cystectomy, were analyzed, with regard to impact on survival and time to recurrence in bladder cancer patients.

Methods: 170 patients who underwent radical cystectomy for urothelial carcinoma between January 1997 and December 2005 were analyzed. 69 of the patients were subjected to limited lymph node dissection and 101 patients underwent extended lymph dissection.

Results: Pathological pT3 and pT4a tumors were more common in the extended (48%) than in the limited dissection group (33%). The median numbers of lymph nodes removed were 37 and 8. Lymph node metastases were found in 38% and 17%, respectively. No differences in survival or time to recurrence were found between the groups. However, in a multivariate analysis adjusting for tumor stage, lymph node status, age, sex, and adjuvant chemotherapy there was an improved survival (HR 0.47, 95% CI 0.25–0.88; p = 0.018) and time to recurrence (HR 0.42, 95% CI 0.23–0.79; p = 0.007) in the patients with extended lymph node dissections. Subgroup analyses showed a longer time to recurrence (HR 0.45, 95% CI 0.22–0.93; p = 0.032) in patients with non-organ-confined disease who underwent extended lymph node dissection.

Conclusions: Extended lymph node dissection was related to improved disease-specific survival and prolonged time to recurrence in radical cystectomy patients. These results should be interpreted cautiously, as they might have been affected by stage migration and shorter follow-up in the extended dissection group.

 

               

JB Jensen¹, BP Ulhøi², KM Jensen¹

¹Department of Urology and²Institute of Pathology, Aarhus University Hospital, Aarhus Sygehus NBG, Aarhus, Denmark

jb@doktor.dk

 

Aim: The present study provides an evaluation of the usability of size and volume of lymph nodes (LNs) in the pelvis and lower abdomen to predict metastatic disease in patients with carcinoma of the urinary bladder.

Material and methods: LNs retrieved from 157 patients undergoing radical cystectomy and extended lymphadenectomy to the level of the inferior mesenteric artery were registered with number, location, presence of metastatic disease, longitudinal and axial length and a calculated LN volume.

Results: A mean of 21.2 LNs were removed from each patient. Thirty-two patients (20.4%) had metastatic disease. There were no significant differences between size of negative LNs compared to size of positive LNs and no optimal cut-off value predicting metastatic disease based on LN size could be found. Analysing calculated volume of each LN and total LN volume per patient did not contribute with useful information as to prediction of metastatic disease. Total LN volume per patient was found to be independent of number of LNs removed while mean volume per LN was inversely proportional with number of LNs removed in node negative patients.

Conclusions: Size of LNs remains a poor predictor of metastatic disease in bladder cancer. A fixed volume of lymphatic tissue rather than a fixed number of LNs seems to be present in node negative patients.

 

               

T Maigaard, BP Ulhøi, K Zieger

Departments of Urology and Pathology, Aarhus University Hospital, Skejby, Århus, Denmark

karsten.zieger@ki.au.dk

 

Objective: The 1998 WHO/ISUP consensus conference revised the pathological classification of bladder neoplasms, introducing “papillary urothelial neoplasms of low malignant potential (PUNLMP)”. The clinical significance of this entity with regard to risk of progression and follow-up policy is still debated. Scientific evidence is sparse. In Scandinavia, a very similar category has been used routinely for decades: stage Ta Bergkvist grade 1.

Methods: In a cohort of 1176 patients with primary bladder tumors, we identified 113 patients with Bergkvist grade 1 lesions. Pathology slides were reviewed according to the 1998 WHO classification. Voided urine cytology was taken routinely. No adjuvant treatment was given. The patients were followed in a routine schedule, and censored at last cystoscopy.

Results: Follow-up was mean 50 (range 4-128) months. No progression to muscle invasive stages was observed. Lamina propria invasion (stage T1) or high-grade lesions were seen in 11 patients (10%). In eight of these, cytology was positive at debut. The specificity of cytology as a marker of “progression” was 93%. 61 patients (54%) suffered recurrence, which in 53 cases (87%) occurred within 2 years.

Conclusion: PUNLMP hardly, if ever, progress to muscle invasive cancer, but may develop high-grade or superficially invasive disease in about 10% of cases. Two years cystoscopic follow-up with urine cytology appears to be a reasonable safe follow-up regimen for this type of tumors.

 

               

N Fristrup^1,2, L Dyrskjøt², TF Ørntoft², BP Ulhøi³, M Borre¹

Departments of Urology¹, Molecular Medicine² and Pathology³, Aarhus University Hospital, Denmark

NFR@studmed.au.dk

 

Aim: The superficial tumors of the bladder form a heterogeneous group regarding risk of recurrence or progression and consequently the patients have to be monitored thoroughly and thereby become a major burden for health care systems. The aim of the study is to identify markers that can predict the outcome for each patient.

Materials & methods: This study is based on long-time follow-up on prospectively collected data and tissue at Aarhus University Hospital. A total of 289 primary urothelial tumors were chosen for tissue microarray fabrication. 118 patients progressed to pT2-4 bladder cancer during a median follow-up of 74 months. None of the remaining 171 patients progressed. Protein expression was investigated using immunohistochemistry.

Results: Presence of cytoplasmatic Cathepsin E proved to be an independently significant variable associated with evasion of disease progression after adjusting for stage, WHO grading, CIS and BCG (HR: 0.64; P=0.039). The percentage of nuclear Maspin correlated significantly with evasion of disease progression (HR: 0.57; P=0.012), (not shown). Regarding the presence of cytoplasmatic Maspin we found the inverse correlation in a multivariate analysis (HR: 1.66; P=0.030).

Conclusions: Cathepsin E and Maspin might contribute to a new generation of prognostic markers stratifying risk and thereby potentially having a major impact on future therapeutical strategy, human survival rates and health care economics.

 

               

R Røtterud, A Svindland, R Wahlquist

OsloUrological University Clinic, Oslo University Hospital, Aker, Trondheimsvn, Oslo, Norway

ranveig.rotterud@medisin.uio.no

 

Aim: Mutated FGFR3 is overexpressed in low-grade bladder tumours. We mapped wild-type FGFR3 expression in T1 tumours and compared with previously published results from advanced tumours and normal bladder mucosa.

Materials and methods: Immunostaining of T1 UCC from 85 patients was done with an N-terminal (B9) and a C-terminal antibody (C15) against FGFR3. Scoring was done in membrane and cytoplasm (B9), or cytoplasm and nucleus (C15). No nuclear staining was seen for B9.

Results and discussion: The predominant (74%) staining profile for B9 was neg/+++ (mem/cyt). C15 separated the T1-tumours in 3 subgroups: 19% stained “normal”: neg/+++ (cyt/nuc) (like 93% of normal urothelium samples). 52% of the T1 tumours had a “malignant” profile: +++/+++ (cyt/nuc) (like 76% of metastasised UCC). The difference was significant when normal, T1, and advanced tumours were analysed together (Kruskal-Wallis), and also in each of the pairwise comparisons (Mann-Whitney). Mean survival differed by 18 months from the “normal” group to the “malignant” group (71 vs. 53), although not significant.

Conclusion: C15 staining is consistent with a function as a prognostic factor. We hypothesise 1) the receptor is cleaved in the cytoplasm, 2) the C-terminal part translocates to the nucleus, 3) this process is beneficial for the carcinogenesis, leading to reduced survival for the patients. If mutations in FGFR3 interfere with this process, this can explain why mutFGFR3 is overexpressed in low-grade tumours.

 

               

M Brehmer, C Malm

Department of Urology, Karolinska University Hospital and Södersjukhuset, Sweden

camillamalm@yahoo.com

 

Introduction: The aim was to investigate the outcome of organ-sparing treatment of UUTTCC

Methods In a prospective study, April 2005 October 2008, 16 patients with UUTTCC underwent organ-sparing treatment. Indications were solitary kidney, bilateral tumour, renal impairment, high co-morbidity or patient’s refusal to undergo nephroureterectomy. Ureteroscopically, tumour biopsy and cytology were taken followed by laser ablation of the tumour. Patients were followed ureteroscopically every 3 months 4 times and then at extended intervals if no recurrence occurred. Additional treatment with BCG or mitomycin was considered if high-grade cancer or broad based tumor or if recurrence occurred.

Results: Mean follow-up time was 18.5 months (median 17.5). Mean age was 72.4 years (range 41-89). 6 patients had solitary kidney, 5 because of contra lateral UUTTCC, 1 patient had impaired renal function, 1 had bilateral tumour, 8 had co-morbidity precluding nephroureterectomy and 2 patients insisted on organ-sparing treatment. 12 patients had previous history of bladder cancer. In 2 patients the tumour was located in the renal pelvis, whereas in 14 patients the tumour was located in the ureter. Tumour size was <15 mm in 8 patients and >15 mm in 8 patients. Cytology was benign in 5 cases, G1 in 5, G2 in 2, G3 in 1, atypical in 2 and missing in 1 patient. Tumor biopsy revealed G1 in 7 cases, G2 in 1, G3 in 3 and was atypical or undeterminable in 4. Four patients received additional BCG.Recurrence occurred in two patients with G2 tumours > 15 mm, after six and eighteen months respectively. Both were retreated ureteroscopically and one the patients also received additional Mitomycin because of high-grade cancer. After 2 instillations he had an inflammatory reaction in the ureter and developed a stricture that has been handled endoscopically.

No other patients have had any severe complications.

Conclusion: Laser treatment of UUTTCC in selected cases is a safe and promising treatment. However, regular, long time endoscopic follow-up is necessary.

 

               

OJ Nilsen, Aa Andersen, CM Solend, A Schultz

OsloUniversity Hospital, Rikshospitalet, Department of Urology, Norway

ojnil@broadpark.no

 

Aim of investigation: Enterocystoplasty is an established treatment of idiopathic detrusor over activity (IDO) and neurogenic detrusor over activity (NDO) when conservative treatment has failed. The aim is to reduce detrusor contractility and increase bladder capacity. This study is an objective and subjective evaluation of the long term results after enterocystoplasty in patients with IDO and NDO.

Material and methods: Patients with IDO or NDO, operated with ileocystoplasty between 1990 and 2005 (72 in all) were identified. Six patients were not alive, and 7 (9.7 %) had received an ileal conduit. 59 patients were scheduled for follow up with cystometry, cystoscopy and interview. Six patients did not show up. Mean time of follow up in the included 53 patients was 7.1 years (range 2.3 – 17.9).

Results and discussion: There was no mortality. Two patients had a pulmonary embolism, one patient had sepsis, and one patient had a wound dehiscence.Mean Maximal Cystometric Capacity increased from 307 ml (± 138) preoperatively to 507 ml (± 112) at follow up (p<0.001). Mean Maximal Detrusor Pressure decreased from 54 cmH₂0 (± 37) to 14 cmH₂O (± 13) at follow up (p<0.001). Cystoscopy showed no malignancy or stones.

The questionnaire regarding satisfaction was answered by 52 patients. 29 patients were very satisfied, 18 were satisfied, 3 were dissatisfied and 2 were very dissatisfied. Overall 47 patients (90 %) report to be very satisfied or satisfied with the results.

Conclusions: Enterocystoplasty isefficient in increasing bladder capacity and reducing detrusor contractility in patients with IDO or NDO. There are few major complications, and the patient satisfaction with the result is good.

 

MG Madsen^1,2, R Nørregaard², JH Christensen³, J Frøkiær², TM Jørgensen¹

¹Department of Urology, Aarhus University Hospital Skejby, ²The Water and Salt Research Center, Institute of Clinical Medicine, University of Aarhus, ³Research Unit for Molecular Medicine, Aarhus University Hospital Skejby, Aarhus, Denmark

miagebauermadsen@ki.au.dk

 

Aim: To examine whether a potential change in the concentration of urinary cytokines after release of unilateral ureteral obstruction (UUO) reliably reflects changes in the renal parenchyma.

Material and methods: A 48 hour UUO rat model was used. Urine samples were collected selective and kidneys were either dissected and homogenised or prepared for immunohistochemistry. Sham-operated rats were prepared in parallel. Urine and tissue cytokines were measured with a multiplex assay for Luminex.

Results and discussion: We found an increased expression of IL-1b, IL-6 and TNF-a in the obstructed kidney and corresponding to this, significant higher levels of these cytokines in urine from the obstructed kidney. Importantly, we also found increased levels of IL-10 in urine from the non-obstructed kidney, contrary to urine from the obstructed kidney in which the level was below detection limit. There is a correlation between the concentration of these inflammatory cytokines in renal parenchyma and in urine, and the urinary level may reflect the progression of the renal damage in UUO.

Conclusions: Hydronephrosis is an important cause of renal failure in children. A combination of urinary biomarkers may be useful in predicting which patients will require surgery and in which patients the hydronephrosis will resolve. Further studies (PUUO rat model and humane studies) are required to confirm the diagnostic accuracy of IL-1b, IL-6, IL-10 and TNF-a in urine, and their potential as biomarkers.

 

               

LA Gunnell¹, S Ágústsdóttir¹, J Smári¹, HB Valdimarsdóttir²

¹Department of Psychology, School of Health Sciences, University of Iceland, Reykjavík, Iceland, ²Department of Oncological Sciences, Mount Sinai School of Medicine NY, NY, USA

livanna99@hotmail.com, sjofn@salomonehf.com 

 

Aims: The aim of the current study was to examine the levels of decisional conflict experienced by Icelandic prostate cancer survivors and its relationship with distress as measured by anxiety, depression, intrusive thoughts about prostate cancer and avoidance symptoms.

Material and methods: Prostate cancer survivors completed questionnaires assessing; 1) depression and anxiety; 2) intrusive thoughts about prostate cancer; 3) conflicts regarding the treatment decision. In addition participants completed questionnaires on demographic and medical variables.

Results and discussion: There was a great variability in all of the decisional conflict variables as well as the distress variables. There was a significant correlation between decisional conflict total scores and distress as measured by depression, anxiety and intrusive thoughts about prostate cancer. The decisional conflict subscales, lack of support, uncertainty, feeling uninformed and having unclear personal values were associated with higher levels of depression and anxiety. In addition, the subscales lack of support and uncertainty were associated with higher levels of intrusive thoughts about prostate cancer.

Conclusion: The results indicate a great variability in the degree of decisional conflict among prostate cancer survivors but those with high levels of decisional conflict also reported higher levels of depression, anxiety and intrusive thoughts about prostate cancer. The results suggest that prostate cancer may need more support with their treatment decision in order to minimize the risk of decisional conflict and related distress.

 

               

SÓ Lárusdóttir¹, Á Kristinsdóttir¹, K Jónsdóttir¹, S Ágústsdóttir¹, J Smári¹, HB Valdimarsdóttir²

¹Department of Psychology, School of Health Sciences, University of Iceland, Reykjavik, Iceland, ²Department of Oncological Sciences, Mount Sinai School of Medicine NY, NY, USA

sjofn@salomonehf.com 

 

This study aimed to look at distress and quality of life among Icelandic prostate cancer survivors. Prostate cancer is the most frequently diagnosed cancer and a second leading cause of cancer deaths among men in the Western world. The disease and its treatment can have various undesirable side effects, both physical and psychological, but distress levels have been shown to vary. Prostate cancer survivors, identified through the Icelandic Cancer Registry, were offered via mail to participate in the study and 184 (48%) questionnaires were returned. The sample was neither limited to a specific stage of the cancer at diagnosis nor treatment. The questionnaire package included demographic and medical questions as well as questions on depression, anxiety, quality of life and intrusive thoughts about prostate cancer.

The results revealed that on average, participants experienced little distress and good quality of life, however, individual results varied greatly. Younger men experienced more distress and marriage was linked to better quality of life. Those who were diagnosed with localized cancer had lower distress levels and higher levels of quality of life. Measures of distress and quality of life also varied depending on which treatment the patients received, those who underwent radiotherapy felt worse than those who had a radical prostatectomy.

The results are an important step towards identifying and developing treatment for the subset of patients who are most at risk for experiencing emotional distress.

 

               

H Vasarainen, A Rannikko

Department of Urology, Helsinki University Central Hospital, Finland

hanna.vasarainen@hus.fi

 

Introduction: Active surveillance has emerged as an alternative treatment option for men with localized, small and well-differentiated prostate cancer instead of immediate curative treatment. Active surveillance aims at avoiding overtreatment and thereby minimizing the treatment related side-effects. PRIAS study (Prostate Cancer Research International: Active Surveillance) is a prospective international multicenter study based on strict inclusion and exclusion criteria and follow-up scheme (1,2). Here we report our initial findings in the Finnish arm of the study.

Methods: The PRIAS study started internationally in December 2006 and 698 patients were recruited by the time of analysis; 88 (13%) of them from Finland. Inclusion criteria are: histologically proven prostate carcinoma in 1 or 2 biopsy cores, Gleason score 3+3=6, clinical stage T1c or T2, PSA level ≤10, PSA density ≤0.2 and no previous treatment for prostate cancer. Patients have to be fit for curative treatment.

Results: Mean age at diagnosis (of our 88 patients) was 63 years (range 45-77), PSA 5.3 ng/ml (1,0-9,5), free PSA 18% (3-68) and mean prostate volume was 43 cc (15-100). In 85 (97%) of these patients 12 biopsy cores were taken at the time of diagnosis and 64 (73%) had only one positive biopsy. Initially 85 (97%) had Gleason score 6 (3+3) adenocarcinoma in biopsies.

Median follow-up was 13 months (1-25). 77 (88%) men were still on active surveillance by the time of analysis and 11 (13%) had been treated curatively. Median time of 15 months (7-26) was observed for patients changing treatment. Reason for changing treatment was protocol based in 10/11 cases: five (46%) patients because of more than 2 positive biopsy cores in rebiopsies, three (27%) because of PSA-DT <3 years, one (9%) because of Gleason score >6 in rebiopsies. One patient had >2 positive rebiopsy cores and Gleason upgrading (>6). Only one patient wanted to stop active surveillance based on anxiety or request. Active therapies elected by men coming off surveillance were radical prostatectomy in four patients, external beam radiation therapy in three and brachyterapy in two.

Conclusions: Active surveillance is an emerging treatment modality in “low-risk” prostate cancer. However, there is substantial lack of prospective data regarding this treatment. PRIAS study is the largest prospective trial assessing active surveillance and the preliminary data from the Finnish arm of the study are encouraging.

After a short follow-up a strict adherence to the follow-up protocol was observed and only one patient changed treatment because of anxiety. Therefore surveillance related psychological distress does not seem to be as common as suggested earlier (3). Oncological results are awaited.

 

               

R Zare

Drammen Hospital, Norway

zare@sabhf.no

 

Internal study was undertaken to assess: 1-Adequate anesthesia for prostate biopsy. 2-To assess level of pain after the procedure. 3-To observe relation between age and the level of pain. 4-Incidence of infection with and without invasive anesthesia

Methods and materials: 196 patients in 3 groups.-Group 1 (G1) No anesthesia (n=57)-Group 2 (G2) received 1g paracetamol 1 hour before biopsy and xylocain gel 20 ml rectal 10 min before biopsy + paracetamol 1g x 3 on day 1 (n=69) -Group 3 (G3) received xylocain inj. 10ml periprostatic 5min before procedure (n=70)-All patients received tbl. Ciproxin 500mg 1 hour before and 2 tbl post procedure -Vas scale

 

Result: pain during procedure			Result: pain post procedure
Groups	Mean     SD	P.value	Groups	Mean      SD	P.value
G1=No anes (n=57)	3.46      2.33	G1:G2=1.0	G1=No anes (n=57)	1.6         1.88	G1:G2=0.850
G2=paracet+gel (n=69)	3.42      2.63	G1:G3=0.012	G2=paracet+gel (n=69)	1.3         2.03	G1:G3=0.995
G3=inj.xyl (n=70)	2.27      1.93	G2:G3=0.007	G3=inj.xyl (n=70)	1.54       2.17	G2:G3=0.910
F.test=0.003                                                                                                            F.test=0.739

               

Infection: Total = 4.1%G1+G2 =2.9 G3=8.6

Conclusion: No significant difference in level of pain was observed between group 1 and group 2 during the procedure.

Lower level of pain in group 2 after the procedure but not significant. Significant lower level of pain was observed during the procedure in group 3.Significant lower pain in elderly patient by regressionscoeff.= 0,049; p-value = 0,013. Significant increase in risk for infection was observed in group 3 (invasive anesthesia), but big confidence interval to odds ratio because of low number of patient with infection.

 

               

V Berge, E Baco, SJ Karlsen

OsloUrological University Clinic, Aker University Hospital, Oslo, Norway

viktbe@online.no

 

Aim: To evaluate the efficacy and safety of HIFU salvage therapy for patients with local relapse after external beam radiation therapy (EBRT).

Material and methods: Between October 2006 and April 2008, 36 patients with recurrence after EBRT were treated with salvage HIFU treatment. There is adequate follow-up of 23 of these patients. Mean age 66.5 ± 7.4 years. Mean PSA at diagnosis (pre-EBRT) was 23.3 ± 18.6 ng/ml.

Gleason score pre-EBRT:
Gleason score	3+3	3+4	4+3	4+4	5+4	Unknown	WHO 1	WHO 2
N	7	2	2	4	1	3	1	3

 

 

Clinical stage pre-EBRT:
Clinical T-stage	T1	T2	T3	Unknown
Number of patients	3	4	14	2

 

 

Nadir PSA post-EBRT was 0.7 ± 0.7 ng/ml. Mean time between EBRT and HIFU was 76 ± 42 months. Mean prostate volume pre-HIFU was 20.0 ± 6.2 ml.

Mean PSA pre-HIFU was 4.9 ± 4.7 ng/ml. Mean follow-up was 6 months (range 3 – 18 months).

Results: Mean post-HIFU was PSA 0.9 ± 1.4 ng/ml. There were nine failures (39%) defined as PSA nadir >0.5 ng/ml. There was one case of urethro-rectal fistulae which was treated conservatively with prolonged urinary bladder catheter. There were three patients on endocrine treatment pre-HIFU, all of whom are without endocrine treatment at the time of follow-up.

Conclusion: Our patient material so far is quite small and the follow-up periods are too short for significant conclusions. In selected patients with good initial prognosis, HIFU seems to be a viable salvage treatment option with a curative intent with an acceptable morbidity.

 

               

V Berge, E Baco, SJ Karlsen

OsloUrological University Clinic (OUU), Aker University Hospital, Oslo, Norway

viktbe@online.no

 

Aim: To evaluate the efficacy and safety of HIFU as primary treatment of prostate cancer.

Material and methods: Our patients consisted of men not suitable for standard curative treatments (radical surgery or radiation treatment) or patients not willing to undergo standard treatment. During June 2006 and December 2007 16 patients were treated, 13 of whom have adequate follow-up to date. Mean age 69.4 ± 6.7 years. Median PSA was 7.5 ng/ml at diagnosis (range 1.5 – 546). Mean prostate volume was 22.8 ± 6.3 ml. Mean follow-up was 12 months (range 6 – 24 months).

 

Gleason score	3+3	3+4	4+3	4+4
Number of patients	7	3	1	2

 

 

Clinical T-stage	T1	T2	Unknown
Number of patients	6	6	1

 

Results: Mean PSA 1.8 ± 2.3 ng/ml. So far there have been two patients with PSA recurrence defined as PSA nadir + 2.0 ng/ml and two patients had a positive rebiopsy. One of these patients had re-treatment with HIFU and PSA is now stable. There were no urethro-rectal fistulas.

Conclusion: Our patient material so far is quite small and the follow-up periods are too short for significant conclusions. However, for selected patients primary HIFU may be curative with an acceptable morbidity.

 

               

YH Wang, G Frithz, T Lindeborg, G Ronquist G

Dept. of Surgery and Urology, Dept. of Internal Medicine, Mälar Hospital, and Dept. of Medical Sciences, Clinical Chemistry, University Hospital, Uppsala, Sweden

info@drwang.se

 

Aim of investigation: Captopril being an inhibitor of angiotensin I-converting enzyme was associated with a substantially reduced risk of developing prostate cancer. About 30 % of the patients will have PSA relapse after laparoscopic radical prostatectomy (LRP). The aim of the present study was to investigate, whether captopril given in a low dose postoperatively can reduce PSA-relapse after LRP.

Materials and methods: A total of 62 patients, who underwent LRP by a single surgeon in one centre since 2000, were divided into two groups according to the date of birth. 32 patients with odd number of birthday received captopril 12.5 mg twice daily (captopril group) and other 30 did not receive the medicine (control group). Three were no significant differences in patients’ ages, prostate volume, pre-op PSA, Gleason score, operation time, and blood loss between these 2 groups. All patients were followed up in accordance with a study protocol more than 3 years.

Results: No patients died of prostate cancer in any of the two groups. There patients had PSA-relapse in the captopril group while 10 patients had PSA-relapse in the control group (p=0.034). Mean follow-up time was 38 months.

Conclusions: A significantly lower rate of PSA-relapse was observed in 32 men receiving captopril postoperatively compared to a control group of men not receiving captopril. Because of little side effects and low costs, further enlarged multicenter studies are warranted.

 

               

A Haidar¹, M Jønler¹, TB Folkmar² , L Lund¹

Department of Urology¹, Department of Oral and Maxillofacial Surgery², Viborg Hospital, Denmark

dr.ll@dadlnet.dk

 

Introduction: The use of biphosphonates (Zoledronic acid) in the treatment of metastatic bone disease has been on the rise during the last few years. The aim of this treatment is mainly to reduce skeletal related events e.g. pain, pathologic fractures. There have been few reports relating osteonecrosis of the jaw to treatment with biphosphonates.

Material and methods: In a retrospective study we reviewed all of our patients who have been treated with Zoledronic acid during a five-year period (2003 – 2007).

Results: 53 patients, median age 69 years (range 56-81 years) were treated with Zoledronic acid during that period. 51 patients had hormone refractory hormone metastatic prostate cancer and 2 women with metastatic renal cell carcinoma. In this 5 years period, 686 treatments with Zoledronic acid were administrated. There was an average treatment time of 14 months (1-40 months).

Two cases of osteonecrosis of the jaw were registered. In the first case, the patient developed spontaneous osteonecrosis, whereas the second patient developed symptoms after a dental procedure. We have not registered any new cases of this serious complication since our department adopted an obligatory maxillofacial exam to all patients thought to be treated with Zoledronic acid.

Conclusion: Osteonecrosis of the jaw is a rare but a very serious complication to treatment with biphosphonates. Our review shows that this complication could be preventable.

 

               

A Jonsson^1,4, S Hardarson², V Petursdottir², HB Palsdottir^1,4, E Jonsson^1,4, GV Einarsson¹, T Gudbjartsson^3,4

Departments of 1) Urology, 2) Pathology and 3) Surgery, Landspitali University Hospital, 4) Faculty of Medicine, University of Iceland, Reykjavik, Iceland

arj1@hi.is

 

Introduction: The incidence of renal cell carcinoma (RCC) is rising in Iceland. This has been attributed to increased diagnostic activity, such as abdominal imaging of unrelated diseases, rather than changes in the behavior of the disease. The aim of this study was to compare RCCs diagnosed in living patients and at autopsy, but also to investigate the relationship between the incidence of RCC and autopsy findings.

Material and Methods: RCC found incidentally in individuals at autopsy was compared to patients diagnosed alive in Iceland 1971-2005. Stage at diagnosis and tumor histology was reviewed.

Results: 110 tumors were diagnosed at autopsy with a rate of 7.1/1000 autopsies. When compared to patients diagnosed alive (n=913), the mean age at diagnosis was higher in the autopsy group (74.4 vs. 65 yrs.) while male to female ratio and laterality was similar. Tumors found at autopsy were smaller (3.7 vs. 7.3 cm), at lower stage (88% at stage I+II vs. 42%) and at lower tumor grade (85% at grade I+II vs. 56%). Furthermore the autopsy detected tumors were more frequently of papillary cell type (21% vs. 8%). A difference, although smaller, was present when the autopsy detected cases were compared to only incidentally detected RCCs in living patients. After correcting for declining autospy rate (>50%), a slight trend for a reduced rate of autopsy dectected RCC cases was seen during the last 10 years of the period but the difference was not significant.

Conclusion: RCCs diagnosed at autopsy are at a lower stage and tumor grade than in patients diagnosed alive. The autopsy-rate is declining in Iceland, but after correcting for this decline, the rate of RCC detected at autopsy is relatively unchanged. The increase in incidence of RCC is therefore not explained by findings at autopsy.

 

               

SJ Oddsson^1,4, S Hardarson^3, V Petursdottir^3, E Jonsson^3,4, GV Einarsson^3, T Gudbjartsson^1,4

Departments of ¹Cardiothoracic Surgery, ²Pathology and ³Urology, Landspitali University Hospital, ⁴Faculty of Medicine, University of Iceland, Reykjavik Iceland

saemiodds@hotmail.com

 

Objective: The incidence of renal cell carcinoma (RCC) is high in Iceland and about 45 new cases are diagnosed every year. Symptoms are often absent which results in over 30% of patients presenting with metastases (most often pulmonary) when diagnosed. The prognosis in such cases is usually dismal. However, recent findings show that pulmonary metastatectomy in a selected group of patients can improve survival and up to 49%5-year disease free survival has been reported. The aim of the study was to analyze the patients diagnosed with RCC and pulmonary metastasis in Iceland to try to evaluate the how many could possibly benefit from surgery according to recent studies.

Material and methods: This is a retrospective study which includes all patients that were diagnosed alive with RCC in 1971-2000 (n=701). Information was obtained from clinical records, The National Cancer Registry and pathology reports. Tumors were classified with the TNM staging system.

Results: 130 patients had pulmonary metastases, or 18.5% of all patients diagnosed with RCC. In 54 cases, metastases were only detected in the lungs, 8 of them being incidentally diagnosed (14%). 38 (79%) had multiple pulmonary metastasis, 27 (56%) of them with metastases in both lungs. Ten patients were diagnosed with a solitary metastasis and one of them underwent metastasectomy.

Conclusion: Approximately one in five patients has a lung metastasis when diagnosed with RCC. In 44% of cases the metastasis is only in the lungs and 22% are single. Recent findings suggest that some of these could benefit from metastatectomy which has been rare in Iceland. It has to be kept in mind that the study is retrospective (35 years) and the potential of such surgery has only recently been described and has to be evaluated with regard to recent progress in chemotherapy.

 

               

U Møldrup¹, J Solvig², TEB Johansen¹, Ø Østraat¹

¹Dept. of Urology, ²Dept. of Radiology, Århus University Hospital, Skejby, Denmark

Ullmoeld@rm.dk

 

Aim: To evaluate the feasibility, complication rate and short- term oncological outcome of renal cryoablation procedures performed in our department.

Materials and methods: 58 patients underwent cryoablation of 63 renal tumors. 27 patients were ablated percutaneously and 31 laparoscopically. Positioning of the cryoneedles and freezing of the tumor was monitored peroperatively by percutaneous or laparoscopic ultrasonography. Ablation was considered successful when tumors gradually shrunk and showed no sign of contrast enhancement assessed by CT or MR scan.

Results: Median tumor size was 2,2 cm [1,0-4,4] ([min-max]). We used 4 [1-9] cryoneedles. Cryotherapy was feasible in all patients. One patient had a nephrostomy for two days because of haematuria and hydronephrosis. No patients had blood transfusion. One patient developed hydronephrosis, probably because of a thermal ureteric lesion. Median follow-up time was 14 months (range 1-39). The cancer specific survival was 100%. Residual tumor was suspected in three patients, histology at re-ablation showed carcinoma (1pt) and necrosis (1 pt). The third patient will be operated within weeks. No successfully ablated patients have had recurrence so far.

Conclusion: Cryoablation of small renal tumors offers a safe alternative to renal resection or nephrectomy in terms of complications. Care must be taken to identify patients with primary incomplete ablation. Long- term follow-up is needed.

 

               

S Sozen, B Kupeli, I Ure, S Gurocak, I Bozkirli

GaziUniversity School of Medicine, Department of Urology, Ankara Turkey

borakupeli@yahoo.com

 

Aim: To assess our experiences in laparoscopic simple (LSN) and radical nephrectomy (LRN).

Methods: Between July 2006 – July 2008, we performed LSN for non-functioning kidney in 15 (37,5%) patients and LRN for localised kidney tumors in 25 (62,5%) patients. All procedures were performed transperitoneally. Demographic features, operation datas and hospitalization times of the patients were compared.

Results: Mean age of patients were 51,8±14,8 years. The operation time of LSN were significantly shorter than LRN (p=0.001). Mean blood loss during the LRN were 184,7±229,5 ml which was statistically higher than LSN (p=0,002). The mean tumor size and skin incision length for extracting the specimen were 5,43±3,17 cm and 13,4±4 cm respectively in LRN. The drain catheter removal time and hospitalization were shorter in LSN (p=0,003). There were no major complication, however temporary renal function deterioration and bleeding requiring blood transfusion were seen in 2(10.5%) and 1(5.2%) patients, respectively, in LRN group. One LRN patient was converted to open surgery because of insufficient exposure.

Conclusions: With the increasing experience in laparoscopic surgery, all open nephrectomies can be replaced with laparoscopic procedures with the advantage of minimal complications and short hospitalization times. LRN now became the first treatment option in all T1b renal cell carcinoma patients in our clinic.

 

               

NM Stilling, HU Jung, B Nørby, SS Osther, PJS Osther

Department of Urology, Fredericia Hospital, Fredericia, Denmark

palle.joern.osther@slb.regionsyddanmark.dk

 

Objective: Controversy remains regarding the best way to treat ureteropelvic junction obstruction (UPJO). This study evaluated subjective and objective outcome of retrograde endopyelotomy in a selected population with UPJO.

Material and methods: 47 patients above 18 years of age with UPJO in which a very large pelvis, a high insertion of the ureter, a renal split function below 20% or a long (>2 cm) stenosed ureteropelvic segment were excluded. Renal function was estimated on renal diuretic scan before and after surgery with a mean renographic follow-up of 35 weeks. Subjective results were based on questionnaires (mean follow-up 110 weeks). Success criteria were defined as symptom relief and improved or preserved renal function.

Results: Twenty-nine patients (66%) experienced complete symptom resolution and 10 patients (23%) had significant symptom improvement (i.e. no need for pain-killing medication). Five patients (11%) had unchanged symptoms. No difference in postoperative renal function was observed between these three groups of patients. No major complications were observed.

Retrograde ureteroscopic endopyelotomy is a safe and effective treatment option in patients with primary and secondary UPJO when selected properly.

 

               

YF Rawashdeh, LH Olsen, TM Jørgensen

Department of Urology, Aarhus University Hospital – Skejby, Aarhus, Denmark

yazan@ki.au.dk

 

Aim: To present a case of robotic retroperitoneoscopic pyeloplasty in a duplex kidney.

Methods: Ten Year old girl presented with a history of left sided flank pain and recurring episodes of pyelonephritis. Imaging revealed a left sided incomplete duplex system with severe dilatation of the lower moiety. Ureteropelvic junction (UPJ) obstruction of the lower moiety was confirmed by retrograde pyelography.

The patient was operated in the right lateral position. Access to the retroperitoneal space was obtained by a muscle splitting incision below the XII rib, and the space was developed by balloon dissection. Two 8 mm working ports and an accessory 5 mm port were established maintaining adequate triangulation.

The collecting systems of the duplex kidney were identified, with obvious stenosis of the lower moiety UPJ. The ureter was incised in a “U” shaped fashion along the confluence of the two systems. The anterior wall was closed by a running 6 – 0 absorbable suture. A 4.7 F multipurpose stent was placed with its lower end in the ureter, upper end in the upper moiety and the loop across the lower moiety UPJ. Finally the posterior wall was closed.

Results: Operative time was 150 minutes. There were no per or postoperative complications. Hospital stay was 2 days. Three months post surgery the patient was asymptomatic, and ultrasound showed no residual dilatation.

Conclusions: Robotic retroperitoneoscopic pyeloplasty is a minimally invasive procedure, giving direct access to UPJ and offers excellent overview which allows tackling both normal and anomalous anatomy.

 

               

P Nencka¹, R Zachoval¹, V Vik¹, V Borovicka¹, J Granatova²

¹Department of Urology and ²Department of Clinical Biochemistry, Teaching Thomayer’s Hospital, Prague, Czech Republic

petr.nencka@ftn.cz

 

Aim: To asses the dynamics of serum concentrations of procalcitonine (PCT) in patients with acute non obstructive pyelonephritis in comparison with other markers of acute inflammation (CRP, leucocytes) and to asses the potential use in diagnostics and therapy.

Material and methods: The prospective study included 20 patients with clinical symptoms and positive leucocytes in urinary sediment admitted to our department in the period 5/07-3/08. Antibiotic monotherapy was dispensed empirically. The levels of markers at the time of admission, after 24 and 72 hours (h) were assessed.

Results and discussion: All cases showed good response to the therapy after 48h in average (3-72). The average level of PCT at the admission was 0.35 ug/l, after 24h 1.398 ug/l and after 72h 0.48 ug/l. The average level of CRP was 131.8 mg/l at the admission, after 24h 159.1 mg/l and after 72h 111.9mg/l. The average level of leucocytes was 14.600/ml at the admission, after 24h 12.600/ml and after 72h 6.800/ml. The elevation of PCT was not detected in 7 cases (35%) in any of examination performed while the elevation of other markers was present. The levels of PCT and CRP culminate in first 24h followed by decrease in 72h. The level of leucocytes culminates before the therapy starts followed by decrease in 24 and 72h.

Conclusion: The use of PCT as a universal marker in diagnostics and therapy of acute pyelonephritis in adults is limited by significant number of normal values of PCT detected in our series.

 

U Karaoglan, B Kupeli, C Acar, S Gurocak, I Bozkirli

GaziUniversity School of Medicine, Department of Urology, Ankara, Turkey

borakupeli@yahoo.com

 

Aim: To investigate the effect of renal axis on stone formation in lower caliceal stones(LCS).

Methods: The clinical records of patients with solitary lower caliceal stones who underwent SWL were reviewed. After exclusion of patients with hydronephrosis, major renal anatomic anomalies, non-calcium stones, history of recurrent stone disease and previous renal surgery, 96 patients were enrolled into the study. Lower pole infundibulopelvic angle(IPA),infundibular length(IL),width(IW), pelvicaliceal volume and renal axis of both the stone bearing and contra lateral normal kidneys were measured from intravenous pyelography.

Results: The stones were left and right sided in 50 and 46 patients, respectively. The mean renal axis angle of stone-bearing right kidneys and contra lateral kidneys were 16,04°±4,5° and 19,2°±4,7°, respectively(p=0,002). These values were 18,5°±4,7° and 17,2°±5,2° for left stone-bearing kidneys and their contra lateral partners(p=0,15). Lower pole IW(p=0,001) for right kidneys with LCS and lower pole IPA(p=0,001) for left kidneys with LCS were statistically different when compared with contra lateral normal kidneys.

Conclusions: Our study shows that renal axis should also be taken into account especially for right LCS. More acute renal axis -perhaps due to the liver on the right side- may behave as an acute IPA resulting an abnormal urodynamic and morphologic lower calyx for stone formation especially when combined with other anatomical or metabolic factors.

 

               

B Kupeli, U Karaoglan, C Acar, S Gurocak, I Bozkirli

GaziUniversity School of Medicine, Department of Urology, Ankara, Turkey

borakupeli@yahoo.com

 

Aim: To investigate the influence of renal axis on stone clearance after shockwave lithotripsy (SWL) in solitary lower caliceal stones(LCS).

Methods: The records of patients with solitary LCS who underwent SWL were reviewed. After exclusion of patients with hydronephrosis, major renal anatomic anomalies, non-calcium stones, history of recurrent stone disease and previous renal surgery, 96 patients were enrolled into the study. Lower pole infundibulopelvic angle(IPA), infundibular length(IL), width(IW), pelvicaliceal volume and renal axis of stone-bearing kidneys were measured from intravenous pyelography.

Results: The stones were left and right sided in 50 and 46 patients, respectively. Stone-free rate of right LCS was 54,3% and left LCS was 80%(p=0,007). Lower IPA and IW of left LCS were significantly more acute and narrow than right LCS(p=0,03, <0.001). The mean renal axis angle of right kidneys was found 16,04° which was more acute than left kidneys (18,5°,p=0,001).

Conclusions: High success rate in left kidneys despite unfavorable anatomy like acute IPA and narrow IW and low success rate in right kidneys despite favorable anatomy but more acute renal axis in our study suggest that renal axis angle may influence the stone clearance after SWL. More acute renal axis probably rotate caliceal structures and the resulting anatomy can behave as an unfavorable one. So renal axis and stone side should also be taken into account for stone clearance after SWL treatment of LCS.

 

               

PJS Osther, SS Osther

Department of Urology, Fredericia Hospital, Fredericia, Denmark

palle.joern.osther@slb.regionsyddanmark.dk

 

Introduction: The exact role of the diet in the pathophysiology of calcium oxalate (CaOx) stone formation remains to be elucidated. The aim of the present study was to analyse the relation between diet and stone risk in recurrent male CaOx stone formers and healthy males while maintained on free-choice diet.

Material and methods: 118 recurrent male CaOx stone formers and 122 healthy males were included. The participants were asked to keep a 7-day food record. 24-h urines were sampled on a week-day. The risk of CaP and CaOx crystallisation were estimated.

Results: There were no differences in fluid intake and dietary intake of minerals and major nutrients between stone formers and healthy subjects. Risk of CaOx and CaP crystallization were significantly higher in the stone formers compared to controls. Performing a multivariate analysis the characteristic of the male stone formers that most clearly distinguished them from the healthy men was a high level of urine calcium for any given level of citrate.

Conclusion: There seems to be no major differences in the dietary habits of CaOx stone formers and healthy males. Thus, a ‘western’ diet alone does not seem to cause stone formation. The stone formers must have some metabolic abnormality to account for their susceptibility to form calculi. The differences between male stone formers and healthy males in the present study may be indicative of an altered metabolic response to protein catabolism.

 

               

FE Martins, RN Rodrigues, AF Sandul, TM Lopes

Department of Urology, Centro Hospitalar Lisboa Norte, Lisboa, Portugal

faemartins@gmail.com

 

Introduction: We present our experience with the use of a continent neo-urachus-like tract as described by Rackley et al in 4 patients. We also demonstrate the procedure in a step-by-step manner.

Results: Since April 2006, 4 patients (1 male and 3 females) have undergone this procedure in our department. 2 patients developed swelling and serous discharge from the wound that healed after approximately 2 weeks and medical treatment. In the remaining 2, the healing process occurred uneventfully. All patients are performing CISC without problem.

Discussion: Although our experience is limited and long-term results are still unavailable, this procedure appears to be a promising alternative to urethral self-catheterization in well-selected patients, due to its easier abdominal access . Moreover, it avoids all the inconveniences of an intra-abdominal bowel operation.

Conclusion: The described technique is a feasible, simple, surgical procedure, with a high level of acceptance by patients in well-selected cases. It has limited complications.

 

               

FE Martins, JP Marcelino, AF Sandul, TM Lopes

Department of Urology, Centro Hospitalar Lisboa Norte, Lisboa, Portugal

faemartins@gmail.com

 

Introduction: Penile carcinoma is uncommon, but when diagnosed, it is psychologically devastating to the patient and often present a challenge to the urologist. We present organ-sparing surgery based on penile disassembly technique in a 38-year-old patient with carcinoma of the penile glans.

Methods: Biopsy previously performed confirmed stage 1 squamous cell carcinoma. Penile disassembly starts with urethral mobilization. The urethra is lifted together with Bucks fascia. Dorsally, the neurovascular bundle is dissected by blunt and sharp maneuvers. The glans with urethra ventrally and neurovascular bundle dorsally are completely separated from corpora cavernosa. Neurovascular bundle is divided 2cm under the glans cap. The glans is removed after division of the urethra. Biopsy of the margins confirmed that the resection had been adequate. Urethra is spatulated 4cm in length and fixed to the corpora cavernosa. The spatulated portion is used for new glans construction. At proximal level, each corpora cavernosa is fixed to the skin using U-shaped suture in order to avoid post-operative retraction of the penis. Reconstruction of the penile skin is performed as in circumcision.

Results: Six months after surgery good appearance is achieved. Erectile function is completely preserved.

Conclusion: Organ sparing surgery is the method of choice in treatment of low stage, low grade penile carcinoma. It is most important for young patients who desire to maintain a functioning penis. The penile disassembly technique is a radical but very useful approach for satisfactory outcome.

 

FE Martins, JP Marcelino, AF Sandul, TM Lopes

Department of Urology, Centro Hospitalar Lisboa Norte, Lisboa, Portugal

faemartins@gmail.com

 

Introduction: The need for tissue interposition in vaginal repair, particularly in severely damaged urethrovaginal tissues, gives the Martius flap a major role in pelvic reconstructive surgery.

Material and methods: We demonstrate the Martius flap and its island cutaneous variant harvesting and transfer technique in a step-by-step fashion in 27 patients operated on for complex urethrovaginal fistulae due to obstetric trauma and for prosthetic/sling erosions that involved complex vaginal reconstructions.

Results: The procedures were well tolerated and healed uneventfully in the overwhelming majority of the patients. 1 patient developed infection of the donor site, 1 developed necrosis of the flap, and 3 had delayed serous-bloody discharge from the vaginal wound.

Conclusion: The techniques described are feasible, simple, surgical procedures and have limited complications. They remain a useful adjunct in the pelvic reconstructive surgeon’s armamentarium.

 

               

FE Martins, JP Marcelino, RN Rodrigues, AF Sandul, TM Lopes

Department of Urology, Hospital Pulido Valente, and Division of Urology, Hospital S.A.M.S., Lisbon, Portugal

faemartins@gmail.com

 

Objective: Strictures involving the full length of anterior urethra (panurethral) are a demanding reconstructive challenge. The use of buccal mucosal grafts for dorsal onlay patching of the urethra has provided good functional and cosmetic results for these strictures extending from the proximal bulbar urethra up to the external meatus. We report our experience with the use of buccal mucosal grafts (≤2 strips) for reconstruction of panurethral stricture disease.

Patients and methods: From January 1995 to December 2008, a total of 116 patients underwent urethroplasty in our institutions, 11 of whom had a one-stage buccal mucosal dorsal onlay graft procedure through a perineal approach (1 single strip in 9 patients and 2 strips in 2). In those patients in whom the stricture involved the external meatus, a small ventral subcoronal incision was added to repair the most distal segment of the urethra. Penile shaft degloving was avoided in all 11 patients. Buccal mucosal grafting varied between 12 and 17cm. in length.

Results: The median follow-up was 54 months (range 11 to 168). The overall complication rate both at the donor and recipient sites were acceptably low, the main complications being oral numbness in 33% (3 in 11), and delayed difficulty in mouth opening in 18% (2 in 11). No patient developed oral wound infections or experienced changes in salivary function. The stricture recurrence was 11% (1 in 11). Slight ventral curvature on erection occurred in 27% (3 in 11). None developed erectile or ejaculatory dysfunction. No fistula or diverticulum formation occurred.

Conclusion: The single-stage dorsal onlay buccal mucosal grafting procedure through a perineal approach is a good, feasible and reproducible technique for the treatment of panuerthral stricture disease. However, complications are not negligible. Further experience with a larger patient population is needed.

 

               

H Eyjólfsdóttir¹, M Ragnarsdóttir¹, G Geirsson²

¹Department of Rehabilitation and ²Department of Urology, Landspitali University Hospital, Reykjavik, Iceland

halldey@landspitali.is

 

Aim: To compare the effectiveness of pelvic floor muscle training with and without electrical stimulation in treatment of stress urinary incontinence.

Material and methods: Participants were 24 women, 27-73 years of age, diagnosed with stress urinary incontinence. Exclusion criteria were pregnancy and urge urinary incontinence. The participants were randomly divided into group 1 and 2.

The pelvic floor muscles were evaluated using the Oxford scale, vaginal palpation, and by electromyogram, (Myomed 930, Enraf Nonius). The quantity and frequency of urinary incontinence episodes was evaluated using a questionnaire and a VAS scale before and after the treatment.

Both groups trained twice a day for 15 min. Group 2 used simultaneously intermittent electrical stimulation.

Results: The groups were demographically similar, except group 2 was significantly younger. Both groups had significantly increased pelvic floor muscle strength (p=0.007; p=0.005) after the treatment and 70% of all the women had reduced or no stress urinary incontinence. Group 2 had significantly (p=0.013) better relaxation post treatment.

Conclusion: Pelvic floor muscle training was an effective treatment for stress urinary incontinence, but electrical stimulation gave no additional effect for this patient group. The significantly lower relaxation threshold in group 2 indicates, that electrical stimulation could be a possible treatment for symptoms caused by hypertensive pelvic floor muscles.

CU Skagemo^1,2, K Almendingen², A Blindheim³, PE Låhne⁴, GI Meling^1,2

¹Department of Urology and ²Faculty Division, Akershus University Hospital, University of Oslo, ³Department of Urology, St. Olavs Hospital, NTNU, Trondheim, ⁴Department of Urology, Vestfold Hospital, Tønsberg, Norway

carolineskagemo@gmail.com

 

LAB is known to reduce inflammation in IBD, to oust pathogens during vaginitis, improve intestinal microbial balance, and in pilot studies reduce UTI frequency.

We have designed a multi-center RCT to investigate if LAB, orally or vaginally, reduces

- the number of UTIs and/or

- inflammation in the urine or bladder, or improves

- QoL and/or

- immune function and stress markers

To detect a reduction of 33% in UTIs, with a significance level of 2,5% and power 80%, 120 women will be included from patients referred to the urology departments due to recurrent UTIs.

Inclusion criteria are >3 UTIs previous year, ASA score <2, age 18-70, and no found etiology.

Subjects receive daily LAB either vaginally or orally in addition to placebo.

Sputum, plasma, urine, bladder biopsies, questionnaires of QoL and dietary habits are collected before and after 6 months intervention. Monthly self-reports and urine samples are collected.

J Bergqvist, KJ Mikines

Dept. of Urology, Herlev Hospital, Herlev, Denmark

docjesper@me.com

 

Priapism is an urological emergency, usually provoked by the injection of intracorporal vasoactive substances for the treatment of erectile dysfunction.

This is a report of 3 separate cases of priapism, treated at the Dept. of Urology, Herlev Hospital within a period of 8 months. All cases were closely associated with the use of cannabis, and none of the patients had used any other drugs, prescribed or illegal.

This association has never previously been described formally in the medical literature.

A plausible mechanism is discussed.

The problem is probably underreported, and more thorough and systematic research is needed, but use of cannabis should be considered as a triggering factor in otherwise idiopathic cases of priapism.