Based on own experiences and the review of the recent literature, this paper focusses on actual theories about the physics of shock waves (i.e. mechanism of stone disintegration and tissue trauma), actual lithotriptor concepts, new technological developments, and the comparison of lithotriptors. We performed a MEDLINE research, evaluating more than 50 articles on extracorporeal shock wave lithotripsy. In addition, the results of recent experimental and clinical studies performed in collaboration with manufacturers and acoustic phycisists were included in this survey. Today mainly two types of lithotriptors are provided by the companies: an economic ESWL-table or a more sophisticated urolithotriptor. Stone localization is predominantly based on fluoroscopy (isocentric C-arm). There are four discussed mechanisms of stone disintegration: the tear-and-shear forces by reflection of shock waves at acoustical interphases play a major role in the initiation of stone comminution, whereas the role of cavitation is limited to the final process of stone disintegration (together with dynamic fatigue). Recent studies did not support the theory of quasistatic squeezing. Nevertheless, larger focal zones seem to be advantageous, since shock wave energy (not peak pressure) represents the most important parameter for stone fragmentation. Energy density is responsible for shock wave induced tissue trauma, which is mainly caused by cavitation. Electromagnetic sources are used most frequently in new lithotriptors (Siemens, Storz, Dornier, Direx), because of the variabilty of focal zone (i.e. different focussing principles, dual focus), constancy of the impulses, and long-term reliability (more than 1 Mio. shock waves). The clinical comparison of different lithotriptors should be based on modified Efficacy Quotients (i.e. distinguishing between curative and adjuvant auxiliary measures). Recent studies indicate, that actual lithotriptors are able to meet the “gold standard” of the Dornier HM3, however with all advantages of a multifunctional table, high patient comfort (i.e. treatment without general anesthesia) and significantly lower costs. After a decade of minimal changes and progress, exciting technological developments based on a better understanding of shock wave physics are taking place, which will definitively stimulate further research and thus improve the results of extracorporeal shock wave lithotripsy.
The treatment of locally advanced prostate cancer is still matter of debate. While many years ago hormonal treatment (HT) was mostly applied, in recent years the combination of radiotherapy (RT) and HT has been more and more advocated. However, this treatment has never been shown in randomized controlled trials to be superior to surgery without or with adjuvant HT. The surgical approach by radical prostatectomy (RP) has often been discouraged although the results of RP in monotherapy for well-selected patients are excellent. Improvement in staging, a better selection of patients and expert surgery with extensive resection make RP a valuable adjuvant treatment option. Adjuvant therapy with either radiation or hormones can still be applied depending on the definitive pathology of the resected specimen.
Percutaneous nephrolithotomy is a particularly effective procedure, commonly used to treat patients with complex renal calculi. Critical to the success of the procedure is proper patient selection. A thorough preoperative evaluation will serve to optimize treatment outcome. Careful attention to intraoperative details facilitates a safe and efficient access to the collecting system and subsequent stone removal. Postoperative decisions regarding drainage tubes must be well thought out. Performing the procedure as a single stage event optimizes many of these essential points.
Simple and radical cystectomy for the treatment of benign and malignant bladder disease goes back to the late 19th century. The technique has changed over the last century due to increasing surgical experience, improvements in medical technology and pharmacology, an evolving technique of urinary diversion and an increase in patients demand for post-operative quality of life. Approximately two decades ago the orthotopic bladder substitution became popular in male patients, whereas in female patients the use of an orthotopic neobladder to a remnant portion of the female urethra started only a decade ago and still does not include the majority of female patients undergoing cystectomy. The major goal of cystectomy for malignant disease in the pelvis is the oncological outcome. Without compromising tumour resection, however, functional results, i.e. continence, volitional voiding, potency and sexual intercourse play an increasingly important role for this type of surgery. This is especially important for a bladder confined disease which has a better long-term tumour outcome, but on the other hand the use of radical surgery for these stages is still debated in favour of more conservative bladder sparing forms of treatment with less favourable outcome. The technique of radical cystectomy and lymphadenectomy both in male and female patients with regards to preservation of the urethra is outlined. In addition technique of sparing autonomic nerves both to the membranous urethra and the penis or the external and internal female genitalia is described. Surgical variations based on recent anatomic and clinical findings are presented and discussed with regards to the best functional outcome in male and female patients.
Metastatic disease is the cause of death in the majority of cancer patients. Bone marrow is a preferential site of metastasis in breast and prostate cancer, responsible for the majority of skeletal metastases. Micrometastases are often present in the bone marrow of cancer patients and may progress to overt metastases. The survival of these cells and the development of bone metastases depend on the growth support provided by the bone microenvironment and the ability of cancer cells to adapt to this environment, often mimicking the behaviour and gene expression of cells of the bone and bone marrow environment. Experimental evidence suggests that the growth support provided by the bone microenvironment is active during bone resorption. Increased bone turnover as it occurs with hormonal deprivation, therefore, might be a risk factor for developing bone metastases. Interference with bone turnover, however, offers a novel target for preventive and adjuvant therapies. In this review possible mechanisms and factors involved in the development and progression of bone metastases, as well as the molecular, biological and physiological processes of metastases, especially to the bone, are discussed. Furthermore the role of bisphosphonates in the prevention and treatment of bone metastases is reviewed.
Retropubic radical prostatectomy is the most commonly used therapeutic option for the treatment of clinically localized prostate cancer. An ongoing stage migration towards organ-confined cancers allows to perform a nerve-sparing procedure in a growing number of patients. Key elements for achieving convincing functional results are a sphincter preserving ligation of the distal part of Santorini's plexus and the subtle preparation of the neurovascular bundle. This article gives a detailed description of our operative technique. Furthermore, a strategy for patient selection and tumor selection for the indication of nerve-sparing radical prostatectomy (NSRP) is suggested. In addition, functional results addressing postoperative urinary continence and potency are reported.
Since there are no effective therapeutic options for advanced prostate cancer, early detection of this tumour is pivotal and can increase the curative success rate. Although the routine use of serum PSA testing has undoubtedly increased prostate cancer detection, one of its main drawbacks has been the lack of specificity that results in a high negative biopsy rate. Since prostate cancer is a heterogeneous disease, it has become clear that a defined set of markers will provide significantly more diagnostic information than any one biomarker. The list of potential prostate cancer biomarkers will continue to grow. Only when research groups use the proposed guidelines for biomarker development, then systematic evaluation and clinical investigation of these biomarkers will gain more insight into their true diagnostic potential.
Overactive bladder is an highly prevalent syndrome involving up to 17% of the population in both western Europe and US and is often associated with detrusor overactivity. Significant improvement in the management of this condition has recently occurred cause the availability of new drugs. The Medline database has been extensively searched. Research has also involved industrial and private databases available online and specialised in the development of new drugs. Antimuscarinics remain the gold standard in the management of detrusor overactivity although the condition mostly goes undiagnosed in non neurogenic patients suffering from overactive bladder syndrome. A number of receptors other than muscarinics have been investigated as possible new targets although no novel effective drugs have been yet developed. Antimuscarinic drugs dominate medical treatment of symptoms and signs associated with detrusor overactivity although new drugs will hopefully be available in the future based on alternative pathophysiological mechanism.
Urinary diversion is an essential component of the surgical procedure after cystectomy. Replacement with an orthotopic ileal neobladder should be the first choice if external urethral sphincter sparing surgery is possible, offering good long-term function, quality of life and patient's acceptance with few complications. The possible use of a variety of alternative intestinal segments widen the horizon of the reconstructive surgeon, allowing him or her to be prepared for unusual cases. Contraindications for orthotopic neobladder reconstruction include tumour location, reduced renal, liver, intestinal function, intellectual ability and physical handicaps. It is therefore important to custom tailor the appropriate mode of diversion for individual patients with a variety of options available, including ureterocutaneous stomas, intestinal conduits and continent catheterizable reservoirs and orthotopic neobladders. All these techniques require detailed knowledge of the possible metabolic problems encountered by using gastrointestinal segments and how they react in contact with urine. Modern surgical techniques such as nerve sparing surgery have the ability to preserve postoperative continence with voluntarily micturition as well as sexual function. In addition, preliminary experimental data hold great promise that the “off shelf” bladder substitute may become a technique of choice in the future, avoiding common problems encountered using current technqiues.
Most symptomatic urinary stones are found within the ureter. Depending on stone localisation and size, a substantial portion is able to pass the upper urinary tract spontaneously. This process may take days to weeks and the patient has to receive sufficient analgetic and spasmolytic medication. There is some evidence, that alpha-adrenoreceptor blockade supports expulsion of praevesical stones. Standard and least invasive treatment for ureteric stones is extracorporeal shockwave lithotripsy (SWL). However, stone free rate after SWL of ureteric stones after single SWL is lower than for kidney stones and many patients require more than one shockwave application. Recent developments in ureteroscopy (URS) like small-calibre scopes and Ho:YAG laser lithotripsy have changed treatment algorithms as URS is highly efficient, has lower costs than SWL and is still minimally invasive. Especially for larger stones (>10 mm), URS seems to have advantages compared to SWL. Today, open or laparoscopic ureterolithotomy are reserved for special indications and are not used routinely. In summary, SWL offers minimal-invasiveness but a higher risk of treatment failure compared to URS which reaches immediate high stone free rates. Treatment decisions have to be drawn individually taking into account patients preference, personal experience and local equipment.
Uncomplicated urinary tract infection presenting as cystitis or pyelonephritis is common and a significant cause of ill health, although there are generally few sequelae. Unfortunately, the vast body of research now accumulating on predisposing factors and bacterial virulence has had little therapeutic consequence. Nevertheless, standardisation of diagnostic criteria and formulation of guidelines on treatment will go some way to limit the anarchy of excessive investigation and over-treatment which has hitherto contributed to rising antibiotic resistance rates. Truly effective alternative treatments and prophylactic vaccines have yet to be developed.
The rationale for locoregional staging lymphadenectomy in prostate cancer lies in the accurate diagnosis of occult micrometastases in order to stratify patients who might benefit from adjuvant therapeutic measures. In prostate cancer, extended pelvic lymphadenectomy (EPLA) including the lymphatic tissue along the common iliac region with the ureteral crossing as cranial margin, external and internal iliac region and the obturator fossa has been shown to significantly increase the yield of both total lymph nodes and lymph node metastases. The total number of lymph nodes removed is about 2 to 3-fold higher and the frequency of micrometastatic lymph nodes is approximately 2-fold higher compared to standard lymphadenectomy. Furthermore, the frequency of observed positive lymph nodes in clinically localized and locally advanced prostate cancer is significantly higher than predicted by nomograms such as Partin tables and CART analysis. Although there are no prospective randomized trials demonstrating a survival benefit associated with EPLA, there might be an advantage for those with minimal lymph node involvement. Progression-free survival is significantly improved in patients undergoing EPLA with a 35% benefit compared to standard lymphadenectomy. Various studies have documented an equal risk of cancer associated mortality in patients with no or only 1–2 positive lymph nodes. Since the surgery associated morbidity of EPLA is not increased as compared to standard lymphadenectomy, EPLA should be favoured at least for all intermediate and high risk patients undergoing radical prostatectomy; in low risk patients the option of EPLA has to be discussed thoroughly. For the future, ongoing prospective trials have to demonstrate a clear benefit in terms of biochemical free and cancer specific survival.
Bladder cancer is the fifth most common solid malignancy amongst men in the western world. Around 30% of newly diagnosed patients will eventually die from the disease. Radical treatment with curative intent is the best option for patients with invasive bladder cancer. Cystectomy and urinary diversion represents a time-tested robust approach to treating this disease. Here we review the current indications for cystectomy and staging methods for transitional cell carcinoma (TCC). We conducted a search of the current literature to evaluate the evidence for the indications for cystectomy and the staging of TCC of the urinary bladder. Radical cystectomy is usually performed for either invasive or high risk superficial bladder cancer. The outcome is dependent on the pathological stage of tumour at cystectomy. Whilst novel molecular staging methods are in development, current staging is by clinical, pathological and radiological methods. There is a recognised risk of either over- or under- staging the disease using current imaging techniques. The indications for radical cystectomy are changing with more emphasis on surgery for high-risk superficial disease. Better stratification of superficial disease has allowed the identification of such high risk cancers. It is likely that advances in molecular diagnosis and staging will come through to clinical practice in the near future.
The aim of this review is to outline specific surgical complications, metabolic consequences and quality of life (QOL) following urinary diversion in patients undergoing radical cystectomy. Based on a comprehensive literature search (MEDLINE) the published knowledge on urinary diversion was examined regarding the research question with an emphasis on contemporary cystectomy series. Despite the fact, that urinary diversion is commonplace in these days and the existing literature is rather extensive, the vast majority of assumptions are based on low level evidence (retrospective, single-institutional case series with small sample sizes and short-term followup). There are few randomized trials in this field. Early and late surgical complications following radical cystectomy have decreased over the past three decades for both incontinent and continent diversion, but are still significant. While metabolic disturbances are common after continent forms of urinary diversion, the problems can be minimized in most cases. Most reports testify that QOL is high after cystectomy irrespective of type of urinary diversion although urinary and sexual problems are common. Careful patient selection, strict adherence to proper surgical technique and appropriate life-long follow-up are of paramount importance in the successful management of patients undergoing radical cystectomy for bladder cancer.