Markus Hohenfellner

Publications of Markus Hohenfellner

• Pitfalls of electromagnetic tracking in clinical routine using multiple or adjacent sensors.

  Authors: Ingmar Wegner, Dogu Teber, Boris Hadaschik, Sascha Pahernik, Markus Hohenfellner, Hans-Peter Meinzer, Johannes Huber

  The international journal of medical robotics + computer assisted surgery : MRCAS. 04/2012;

  BACKGROUND: While electromagnetic tracking (EMT) holds great promise, there are substantiated concerns about interference within the clinical environment. The purpose of this study was to addressBACKGROUND: While electromagnetic tracking (EMT) holds great promise, there are substantiated concerns about interference within the clinical environment. The purpose of this study was to address accuracy and isolate pitfalls for using multiple or adjacent EMT sensors in clinical routine. METHODS: A phantom simulating an EMT-guided puncture of the kidney was used to analyse the effects of multiple sensors in the direct vicinity, common clinical environments and the influence of endo-urological instruments. RESULTS: No relevant interference due to the investigated instruments was discovered. However, there was a great decrease in accuracy in the vicinity of a C-arm's image intensifier, especially affecting the precision of two adjacent sensors. CONCLUSION: Endo-urological instruments can be safely used for multi-sensor EMT-guided procedures. When avoiding the immediate proximity of the surgical table and the image intensifier, there is a comfortable accuracy corridor. Thus, EMT-assistance is promising for a wide range of procedures if basic conditions are met. Copyright © 2012 John Wiley & Sons, Ltd.

• Penile Methadone Injection in Suicidal Intent: Life-Threatening and Fatal for Erectile Function.

  Authors: Lucas G Prado, Johannes Huber, Christian G Huber, Carolin Mogler, Julia Ehrenheim, Joanne Nyarangi-Dix, Sasha Pahernik, Markus Hohenfellner

  Journal of andrology. 03/2012;

  We present the case of a 31-year-old man who was admitted to our emergency department after injection of 10 ml of methadone into his penis. He had a history of drug abuse over the last 15 years and aWe present the case of a 31-year-old man who was admitted to our emergency department after injection of 10 ml of methadone into his penis. He had a history of drug abuse over the last 15 years and a background of three attempted suicidal episodes with a combination of at least two drugs over the past 12 months. The current suicide attempt had serious consequences: He suffered from acute renal and liver failure. One previously unreported side effect of methadone is erectile dysfunction following injection into the penis. In our case, the patient received vardenafil 10 mg once daily without any signs of functional improvement. Ten months after the event, there still was complete erectile dysfunction.

• Two decades' experience with a prospective biobank for urologic oncology: research, clinical care, and the patients' view.

  Authors: Johannes Huber, Esther Herpel, Hildegard Jakobi, Boris A Hadaschik, Sascha Pahernik, Markus Hohenfellner

  Urologic oncology. 03/2012;

  OBJECTIVES: Collection of clinical data and associated tissue samples has become an essential tool for oncologic research. Since 1990, efforts have been ongoing to implement prospective documentationOBJECTIVES: Collection of clinical data and associated tissue samples has become an essential tool for oncologic research. Since 1990, efforts have been ongoing to implement prospective documentation of all oncologic cases in our department accompanied by a special aftercare program ensuring regular visits and reliable data acquisition. MATERIALS AND METHODS: Our prospective database comprises a total of 6,567 cases covering all types of urologic malignancies: prostate (40.7%), renal (30.5%), urothelial (21.8%), testicular (5.8%), penile (0.8%), and other (0.4%). A specialized full-time documentalist supported by 3 student assistants entered 38,135 aftercare visits characterized by approximately 100 partly disease-specific items. The Institute of Pathology's general collection contains more than 6 million paraffin-embedded samples, and since 2005 the interdisciplinary Tissue Bank at the National Center for Tumor Diseases in Heidelberg has collected about 21,000 cryo-samples. Furthermore, we asked the opinion of 158 patients who attended our clinic for cancer surgery using a self-designed questionnaire. RESULTS: Of 158 patients asked to be included in the biobank, from 09/07 through 02/08, none refused. Their additional questionnaire had a return rate of 81% (n = 128). Moral obligation for supporting medical research was realized by 95%, and circumstantial pressure to participate was not a relevant factor for 87%. Whereas only 68% were hoping for personal benefit, altruism seemed to be a much stronger motive: 96% believe others could be healed because of further medical progress; 93% wanted to be actively informed about recommended aftercare visits. Consequently, response rates in the "Heidelberg Cancer Maintenance Program" are constantly above 93%. Regarding research, a total of 144 scientific inquiries have been answered using our database since 1995. Within the last 5 years, 37 manuscripts originated from biobank data: herein, molecular markers and risk factors have been correlated with clinical outcome. Additionally, TNM-validation studies were conducted. CONCLUSIONS: Prospective collection of clinical data and corresponding tissue has become an indispensable research tool in oncology. In general, patients do not object tissue banking and embrace special aftercare programs.

• External Validation of a Risk Model to Predict Recurrence-Free Survival After Radical Cystectomy in Patients With Pathological Tumor Stage T3N0 Urothelial Carcinoma of the Bladder.

  Authors: Matthias May, Patrick J Bastian, Sabine Brookman-May, Hans-Martin Fritsche, Christian Bolenz, Christian Gilfrich, Wolfgang Otto, Lutz Trojan, Edwin Herrmann, Stefan C Müller [......] Alexander Buchner, Christian G Stief, Derya Tilki, Wolf F Wieland, Markus Hohenfellner, Axel Haferkamp, Jan Roigas, Mario Zacharias, Philipp Nuhn, Maximilian Burger

  The Journal of urology. 02/2012; 187(4):1210-4.

  Patients with stage pT3N0 urothelial bladder cancer vary in outcome after radical cystectomy. To improve prognosis estimation a model was recently developed that defines 3 risk groups forPatients with stage pT3N0 urothelial bladder cancer vary in outcome after radical cystectomy. To improve prognosis estimation a model was recently developed that defines 3 risk groups for recurrence-free survival based on pT substaging, lymphovascular invasion and positive surgical margin. We present what is to our knowledge the first external validation of this risk model. Analogous to the risk model derivation cohort our study group comprised 472 patients with stage pT3, pN0, cM0 disease without perioperative chemotherapy and with a median followup of 42 months (IQR 20-75). The primary end point was recurrence-free survival. The effect of variables was determined by univariate and multivariate Cox regression analysis, and predictive accuracy was determined by ROC analysis. Stage pT3aN0 and pT3bN0 cases showed significantly different recurrence-free survival after 5 years (51% vs 29%, p <0.001). In the multivariate Cox model pT3 substage (HR 1.86, p <0.001), lymphovascular invasion (HR 1.48, p = 0.002), positive surgical margins (HR 1.90, p = 0.030) and patient age with a dichotomy at 70 years (HR 1.51, p = 0.001) had an independent effect on recurrence-free survival. In the low (221 patients or 47%), intermediate (184 or 39%) and high (67 or 14%) risk groups the 5-year recurrence-free survival rate was 55%, 45% and 13%, respectively (p <0.001). The concordance index of the risk model to predict recurrence-free survival was 0.64 (95% CI 0.59-0.69). This user friendly risk model can be recommended to estimate prognosis in patients with stage pT3N0 after radical cystectomy. Patients at high risk showed clearly compromised recurrence-free survival and should be included in adjuvant therapy studies.

• Molecular heterogeneity of TFE3 activation in renal cell carcinomas.

  Authors: Stephan Macher-Goeppinger, Wilfried Roth, Nina Wagener, Markus Hohenfellner, Roland Penzel, Axel Haferkamp, Peter Schirmacher, Sebastian Aulmann

  Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc. 02/2012; 25(2):308-15.

  Renal cell carcinomas associated with Xp11.2 translocations have recently been identified as a distinct biological entity. The translocation results in the fusion of the transcription factor TFE3 toRenal cell carcinomas associated with Xp11.2 translocations have recently been identified as a distinct biological entity. The translocation results in the fusion of the transcription factor TFE3 to one of several different fusion partners including PRCC, PSF, NONO, ASPL or CTLC with consecutive overexpression of the chimeric protein. As the true frequency of these neoplasms as well as the biological properties of TFE3 activation in renal cell carcinomas are largely unknown, we have examined TFE3 expression as well as the underlying genetic alterations in a large, hospital-based series of renal cell carcinomas with long-term follow-up information. Out of a total of 876 tumours, TFE3 translocations were detected in five cases (0.6%). Three additional cases were identified in a second series of cases comprising of renal cell carcinomas developing in patients before the age of 50. However, using immunohistochemistry, 9% of all renal cell carcinomas showed some degree of TFE3 reactivity. Interestingly, these cases were associated with high nuclear grade, greater tumour extent and metastatic disease as well as an unfavourable patient outcome on uni- and multivariate analysis. Fluorescence in situ hybridisation (FISH) revealed TFE3 amplifications as an additional, novel mechanism leading to increased TFE3 expression levels. In conclusion, our data show that Xp11 translocation renal cell carcinomas are uncommon tumours accounting for <1% of adult renal cell carcinomas and that the diagnosis of Xp11 translocation renal cell carcinomas needs to be verified using molecular techniques. In turn, TFE3 overexpressing tumours show an aggressive behaviour and Xp11 translocation is only one of several possible underlying genomic alterations.

• Phantom Study of a novel Stereotactic Prostate Biopsy System Integrating Preinterventional MRI and Live US fusion.

  Authors: Timur Hasan Kuru, Matthias Roethke, Valentin Popeneciu, Dogu Teber, Sascha Pahernik, Pawel Zogal, Heinz-Peter Schlemmer, Boris Hadaschik, Markus Hohenfellner

  Journal of endourology / Endourological Society. 01/2012;

  Introduction and Objective: To determine the targeting error of a novel stereotactic prostate biopsy system, which integrates preinterventional MRI with periinterventional ultrasound for perinealIntroduction and Objective: To determine the targeting error of a novel stereotactic prostate biopsy system, which integrates preinterventional MRI with periinterventional ultrasound for perineal navigated prostate biopsies. Methods: We performed stereotactic biopsies on 5 prostate phantoms (one CIRS 053-MM and four CIRS 066). Phantom 053-MM incorporates three MRI- and TRUS-visible lesions, while lesions within phantom 066 are only detectable on MRI. In both phantoms the 0.5cc volume lesions are randomly placed. The phantoms were examined by 3T-MRI preinterventionally. Then 3 stereotactic biopsies from one lesion in phantom 053-MM and from all ultrasound-invisible lesions in the 066 phantoms were taken under live-fusion-imaging guidance. During intervention a mix of blue ink and gadobutrol was injected into each biopsy channel. Afterwards another 3T-MRI was obtained again. These MRI images were then fused again with the intraoperative TRUS-data. Thus, the targeting error (TE) between the planned and performed biopsy cores could be measured. Additionally, the procedural targeting error (PTE) between the virtually planned biopsy trajectory and the manually registered three-dimensional needle position of every single biopsy core taken was calculated. Results: The overall targeting error (TE) of the 39 biopsy-cores taken was 0.83mm (SD: 0.48mm) with the highest TE in the sagittal plane (1.09±0.54mm), followed by the coronal (0.72±0.43mm) and axial (0.69±0.34mm) planes. The procedural targeting error, which is provided intraoperatively, was 0.26mm in average (SD: 0.46mm). Comparing PTE and TE, there was no statistically significant difference (p=0.39). Conclusion: The targeting error of stereotactic biopsies using our novel perineal prostate biopsy system (BiopSee®, MedCom, Germany) is below 1mm and can be estimated in vivo by the automatically calculated procedural targeting error. Thus, stereotactic prostate biopsies guided by the combination of MRI and ultrasound allow effective and precise examination of MRI-lesions.

• A novel stereotactic prostate biopsy system integrating pre-interventional magnetic resonance imaging and live ultrasound fusion.

  Authors: Boris A Hadaschik, Timur H Kuru, Corina Tulea, Philip Rieker, Ionel V Popeneciu, Tobias Simpfendörfer, Johannes Huber, Pawel Zogal, Dogu Teber, Sascha Pahernik, Matthias Roethke, Patrik Zamecnik, Wilfried Roth, Georgios Sakas, Heinz-Peter Schlemmer, Markus Hohenfellner

  The Journal of urology. 12/2011; 186(6):2214-20.

  We developed an effective way to precisely diagnose prostate cancer using a novel prostate biopsy system that integrates pre-interventional magnetic resonance imaging with peri-interventionalWe developed an effective way to precisely diagnose prostate cancer using a novel prostate biopsy system that integrates pre-interventional magnetic resonance imaging with peri-interventional ultrasound for perineal navigated prostate biopsy. A total of 106 men with findings suspicious for prostate cancer (median age 66 years, prostate specific antigen 8.0 ng/ml and prostate volume 47 ml) underwent multiparametric 3 Tesla magnetic resonance imaging. Suspicious lesions were marked and data were transferred to the novel biopsy system. Using a custom-made biplane transrectal ultrasound probe mounted on a stepper we gathered 3-dimensional ultrasound data and fused them with magnetic resonance imaging data. As a result, suspicious magnetic resonance imaging lesions were superimposed over the transrectal ultrasound data. Three-dimensional biopsy planning was done, including systematic biopsies. Perineal biopsies were taken under live ultrasound guidance and the precise site of each biopsy was documented in 3 dimensions. We evaluated feasibility, safety and cancer detection. Prostate cancer was detected in 63 of 106 patients (59.4%). Magnetic resonance imaging findings correlated positively with histopathology in 71 of 103 patients (68.9%). In magnetic resonance imaging lesions marked as highly suspicious, the detection rate was 95.8% (23 of 24 cases). Lesion targeted cores had a significantly higher positivity rate than nontargeted cores. The procedural targeting error of the first 2,461 biopsy cores was 1.7 mm. Regarding adverse effects, 2 patients experienced urinary retention and 1 had a perineal hematoma. Urinary tract infections did not develop. Perineal stereotactic prostate biopsies guided by the combination of magnetic resonance imaging and ultrasound enable effective examination of suspicious magnetic resonance imaging lesions. Each biopsy core taken is documented accurately for its location in 3 dimensions, enabling magnetic resonance imaging validation and tailored treatment planning. The morbidity of the procedure was minimal.

• Small renal cell carcinoma: oncological outcome with tumour size.

  Authors: Sascha Pahernik, Johannes Huber, Jesco Pfitzenmaier, Axel Haferkamp, Markus Hohenfellner

  Scandinavian journal of urology and nephrology. 12/2011; 45(6):432-5.

  The aim of the study was to analyse oncological outcomes of patients with renal cell carcinoma (RCC) up to 4 cm in diameter. A consecutive series of 396 patients with small RCC was analysed. TumoursThe aim of the study was to analyse oncological outcomes of patients with renal cell carcinoma (RCC) up to 4 cm in diameter. A consecutive series of 396 patients with small RCC was analysed. Tumours were stratified by diameter into three groups: 2 cm (n = 68) for tumours up to 2 cm, 3 cm (n = 172) for tumours between 2.1 and 3.0 cm, and 4 cm (n = 156) for tumours between 3.1 and 4.0 cm in diameter. Tumour stages were distributed into pT1a in 95.6%, 91.9% and 87.0% and into pT3 in 4.4%, 8.1% and 13.0% for the 2 cm, 3 cm and 4 cm groups, respectively. Metastases at the time of diagnosis were found in 2.9% (n = 2), 7.5% (n = 13) and 9.1% (n = 14) of patients in the 2 cm, 3 cm and 4 cm groups, respectively. The tumour-specific survival was 100%, 96.9% and 94.6% at 1 year, 97.5%, 90.3% and 87.5% at 5 years and 97.5%, 87.3% and 84.1% at 10 years for the 2 cm, 3 cm and 4 cm groups, respectively (p < 0.05). Negative prognostic features as well as worse oncological outcome increase with tumour diameter above 2 cm. These data have important implications when considering active surveillance of small renal tumours.

• Patients' View of Their Preoperative Education for Radical Prostatectomy: Does It Change After Surgery?

  Authors: Johannes Huber, Andreas Ihrig, Wolfgang Herzog, Christian G Huber, Beryl Konyango, Eva Löser, Gencay Hatiboglu, Boris A Hadaschik, Sascha Pahernik, Markus Hohenfellner

  Journal of cancer education : the official journal of the American Association for Cancer Education. 11/2011;

  When preparing the evaluation of a newly designed multimedia tool for supporting preoperative education before radical prostatectomy, we realized that the standard procedure has rarely beenWhen preparing the evaluation of a newly designed multimedia tool for supporting preoperative education before radical prostatectomy, we realized that the standard procedure has rarely been investigated. Therefore, we performed semi-structured interviews with 30 consecutive patients the day before and 15 days after radical prostatectomy. Patients' opinion about their preoperative education is decidedly positive and demonstrates intense patient-physician interaction. All patients wanted to be informed about the procedure and possible risks. None reported to be dissatisfied. All but one of the patients (29/30) was able to ask every single question (6.5 mean). Except for signs of forgetting and a slightly altered retrospective assessment of anxiety, we have found no relevant changes over time. Preoperative education is very important to our patients. Therefore, good communication skills should be developed during medical education. A systematic patient-centered approach could further improve the quality of care.

• Gender-specific differences in cancer-specific survival after radical cystectomy for patients with urothelial carcinoma of the urinary bladder in pathologic tumor stage T4a.

  Authors: Matthias May, Patrick J Bastian, Sabine Brookman-May, Hans-Martin Fritsche, Derya Tilki, Wolfgang Otto, Christian Bolenz, Christian Gilfrich, Lutz Trojan, Edwin Herrmann [......] Alexander Buchner, Christian G Stief, Wolf F Wieland, Thomas Höfner, Markus Hohenfellner, Axel Haferkamp, Jan Roigas, Mario Zacharias, Philipp Nuhn, Maximilian Burger

  Urologic oncology. 11/2011;

  BACKGROUND: Bladder cancer (UCB) staged pT4a show heterogeneous outcome after radical cystectomy (RC). No risk model has been established to date. Despite gender-specific differences, no comparativeBACKGROUND: Bladder cancer (UCB) staged pT4a show heterogeneous outcome after radical cystectomy (RC). No risk model has been established to date. Despite gender-specific differences, no comparative studies exist for this tumor stage. MATERIALS AND METHODS: Cancer-specific survival (CSS) of 245 UCB patients without neoadjuvant chemotherapy staged pT4a, pN0-2, M0 after RC were analyzed in a retrospective multi-center study. Seventeen patients were excluded from further analysis due to carcinoma in situ (CIS) of the prostatic urethra and/or positive surgical margins. Average follow-up period was 30 months (IQR: 14-45). The influence of different clinical and histopathologic variables on CSS was determined through uni- and multivariate Cox regression analyses. Two risk groups were generated using factors with independent effect in multivariate models. Internal validity of the prediction model was evaluated by bootstrapping. RESULTS: Eighty-four percent of the patients (n = 192) were male; 72% (n = 165) showed lymphovascular invasion (LVI). The 5-year CSS rate was 31%, and significantly different between male and female (35% vs. 15%, P = 0.003). Multivariate Cox regression modeling, female gender (HR = 1.83, P = 0.008), LVI (HR = 1.92, P = 0.005), and absence of adjuvant chemotherapy (HR = 0.61, P = 0.020) significantly worsened CSS. Two risk groups were generated using these 3 criteria, which differed significantly between each other in CSS (5-year-CSS: 46% vs. 12%, P < 0.001). The c-index value of the risk model was 0.61 (95% CI: 0.53-0.68, P < 0.001). CONCLUSIONS: Prognosis in UCB staged pT4a is heterogeneous. Female gender and LVI are adverse factors. Adjuvant chemotherapy seems to improve outcome. The present analysis establishes the first risk model for this demanding tumor stage.

• Multimedia support in preoperative patient education for radical prostatectomy: The physicians' point of view.

  Authors: Andreas Ihrig, Wolfgang Herzog, Christian G Huber, Boris Hadaschik, Sascha Pahernik, Markus Hohenfellner, Johannes Huber

  Patient education and counseling. 09/2011;

  OBJECTIVE: To systematically assess the physicians' point of view of multimedia support in preoperative patient education for radical prostatectomy. METHODS: We evaluated the view of physiciansOBJECTIVE: To systematically assess the physicians' point of view of multimedia support in preoperative patient education for radical prostatectomy. METHODS: We evaluated the view of physicians performing multimedia supported preoperative educations within a randomized controlled trial. Therein 8 physicians educated 203 patients for radical prostatectomy. RESULTS: All physicians rated multimedia supported education better than the standard procedure. Main reasons were better comprehensibility, the visual presentation, and greater ease in explaining complex issues. Objective time measurement showed no difference between both educations. The major disadvantage was the impression, that multimedia supported education lasted longer. Moreover, they had the impression that some details could be further improved. Given the choice, every physician would decide for multimedia support. CONCLUSION: Physicians appreciate multimedia support in preoperative education and contrary to their impression, multimedia support does not prolong patient education. Therefore, patients and physicians likewise profit from multimedia support for education and counseling. PRACTICE IMPLICATIONS: The readiness of physicians is a possible obstacle to this improvement, as their view is a key factor for the transition to everyday routine. Therefore, our results could alleviate this possible barrier for establishing multimedia supported education in clinical routine.

• External validation of postoperative nomograms for prediction of all-cause mortality, cancer-specific mortality, and recurrence in patients with urothelial carcinoma of the bladder.

  Authors: Philipp Nuhn, Matthias May, Maxine Sun, Hans-Martin Fritsche, Sabine Brookman-May, Alexander Buchner, Christian Bolenz, Rudolf Moritz, Edwin Herrmann, Maximilian Burger, Derya Tilki, Lutz Trojan, Paul Perrotte, Axel Haferkamp, Markus Hohenfellner, Wolf F Wieland, Stefan C Müller, Pierre I Karakiewicz, Patrick J Bastian

  European urology. 08/2011; 61(1):58-64.

  The Bladder Cancer Research Consortium (BCRC) created nomograms to predict all-cause mortality (ACM), cancer-specific mortality (CSM), and recurrence after radical cystectomy (RC) for urothelialThe Bladder Cancer Research Consortium (BCRC) created nomograms to predict all-cause mortality (ACM), cancer-specific mortality (CSM), and recurrence after radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB). To perform a formal validation of the BCRC nomograms in a large multi-institutional patient cohort from Europe. Records of 2501 patients who underwent RC for UCB at eight European centers were reviewed. Complete information for external validation was available in 2404 patients for the ACM and CSM nomograms and in 2243 patients for the recurrence nomogram. For the purpose of external validation, model discrimination was measured using the receiver operating characteristics derived area under the curve. Calibration plots examined the relationship between predicted and observed probabilities at 2 yr, 5 yr, and 8 yr. Decision curve analyses were applied to assess the net benefit derived from the three models. The discrimination accuracies of the BCRC nomograms for ACM and CSM at 2 yr, 5 yr, and 8 yr after RC were 71.0%, 69.1%, and 68.2%, and 74.9%, 73.1%, and 72.4%, respectively. The accuracy of discrimination for the recurrence nomogram at the same time points was 76.5%, 75.3%, and 74.9%, respectively. Calibration plots revealed slight underestimations from ideal predictions. Decision curve analyses showed an increased net benefit for the use of the BCRC nomograms in this cohort. Limitations include the retrospective study design, potential surgeon bias, and lack of a central pathologic review. The ACM, CSM, and recurrence nomograms showed acceptable predictive accuracies and could thus be adopted into clinical practice in UCB patients treated in Europe.

• Multicenter evaluation of the prognostic value of pT0 stage after radical cystectomy due to urothelial carcinoma of the bladder.

  Authors: Matthias May, Patrick J Bastian, Maximilian Burger, Christian Bolenz, Lutz Trojan, Edwin Herrmann, Christian Wülfing, Stefan C Müller, Jörg Ellinger, Alexander Buchner, Christian G Stief, Derya Tilki, Wolfgang Otto, Thomas Höfner, Markus Hohenfellner, Axel Haferkamp, Jan Roigas, Mario Zacharias, Wolf F Wieland, Hans-Martin Fritsche

  BJU international. 06/2011; 108(8 Pt 2):E278-83.

  •To evaluate the characteristics and long-term outcome of patients with pT0 stage after radical cystectomy (RC) for urothelial carcinoma of the urinary bladder (UCB). •Clinical and pathological•To evaluate the characteristics and long-term outcome of patients with pT0 stage after radical cystectomy (RC) for urothelial carcinoma of the urinary bladder (UCB). •Clinical and pathological records of 2403 patients treated with RC for UCB were collected in a multi-institutional database. •The patients met the following criteria: clinical tumour stage cTa-cT2, cN0, cM0, no neoadjuvant chemotherapy or radiotherapy. •Overall (OS) and cancer-specific survival rates (CSS) were calculated for the various clinical tumour stages in relation to their corresponding pathological tumour stage in the RC sample. •Further to this, a multivariable prediction model was developed based on the available clinical data to estimate the probability of tumour stage pT0. •The mean follow-up was 53 months and 132 patients (5.5%) were stage pT0. •Patients with stage cT2-pT0 had a 5-year CSS of 87% vs 69% for cT2-pT2 (P= 0.012) and 57% for cT2-pT+ (P < 0.001). •In a multivariable Cox-model, stage pT0 led to a significant reduction of cancer-specific mortality (hazard ratio0.27; 95% confidence interval 0.12-0.61). •A logistical regression model identified clinical tumour stage (advantage for non-invasive stages) and transurethral resection of the urinary bladder (TURB) time frame (advantage for more recent surgery) as independent predictors for stage pT0. •In muscle-invasive clinical tumour stages, patients with pathological tumour stage pT0 form a subgroup showing a significantly better CSS. •A radical TURB is, assumedly, not causative of this improved survival rate, but rather it is that individual tumour characteristics allow for complete tumour eradication through the TURB procedure. •A TURB with R0 resection is, as such, only a sign of a better tumour prognosis.

• Renal cell cancer--a multimodal approach to preserving renal function and improving survival.

  Authors: Markus Hohenfellner, Sascha Pahernik, Dirk Jaeger, Martin Zeier

  Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 05/2011; 26(10):3086-8.

• Combining open and laparoscopic surgery for partial nephrectomy.

  Authors: Sascha Pahernik, Michael Reiter, Gencay Hatiboglu, Johannes Huber, Jesco Pfitzenmaier, Axel Haferkamp, Markus Hohenfellner

  Journal of endourology / Endourological Society. 05/2011; 25(5):821-4.

  We present a simple and easy to apply surgical approach for partial nephrectomy that combines open and laparoscopic surgery allowing for vascular control in technically challenging renal tumors andWe present a simple and easy to apply surgical approach for partial nephrectomy that combines open and laparoscopic surgery allowing for vascular control in technically challenging renal tumors and for reduction of ischemia time. Five patients underwent partial nephrectomy using the combined laparoscopic/open approach. After complete laparoscopic mobilization of the kidney and securing of the renal vessels, the kidney is transferred extracorporally through a small pararectal incision for tumor resection. The technique was feasible in all cases, with no conversion needed. In three cases, no clamping of the renal artery was necessary. The mean operative time was 219 minutes (range 195-260 min). Pathologic examination revealed no malignancy in two (40%) cases. The estimated median blood loss was 500 mL (range 250-1000 mL). Renal function decreased from 84.9 mL/min (range 48.0-89.0 mL/min) to 78.8 mL/min (range 52.6-82.6 mL/min). Mean hospital stay was 5 days (range 3-14 d). Based on our initial experience, we propose a feasible surgical option for minimally invasive partial nephrectomy, which is, in particular, suitable for technically challenging renal tumors (endophytic and central tumors, large tumors, tumors in solitary kidneys).

• Multimedia article. Navigated renal access using electromagnetic tracking: an initial experience.

  Authors: Johannes Huber, Ingmar Wegner, Hans-Peter Meinzer, Peter Hallscheidt, Boris Hadaschik, Sascha Pahernik, Markus Hohenfellner

  Surgical endoscopy. 04/2011; 25(4):1307-12.

  Navigation systems are promising tools for improving efficacy and safety in surgical endoscopy and other minimally invasive techniques. The aim of the current study is to investigate electromagneticNavigation systems are promising tools for improving efficacy and safety in surgical endoscopy and other minimally invasive techniques. The aim of the current study is to investigate electromagnetic tracking (EMT) for navigated renal access in a porcine model. For our proof-of-principle study we modified a recently established porcine ex vivo model. Via a ureteral catheter which was placed into the desired puncture site, a small sensor was introduced and located by EMT. Then, a tracked needle was navigated into the collecting system in a "rendezvous" approach. A total of 90 renal tracts were obtained in six kidneys using EMT, with a maximum of three punctures allowed per intervention. For each puncture, number of attempts to success, final distance to probe, puncture time, and localization were assessed. We compared absolute and relative frequencies using the chi-square test and applied the Mann-Whitney U-test for continuous variables. No major problems were encountered performing the experiment. Access to the collecting system was successfully obtained after a single puncture in 91% (82/90) and within a second attempt in the remaining 9% (8/90). Thus, a 100% success rate was reached after a maximum of two punctures. Location of the calyx did not have a significant effect on success rate (p = 0.637). After a learning phase of 30 punctures, higher success rate (96% versus 83%; p = 0.041) was accomplished within shorter puncture time (14 versus 17 s; p = 0.049) and with higher precision (1.7 versus 2.8 mm; p < 0.001). With respect to other established techniques, use of EMT seems to decrease the number of attempts and procedural time remarkably. This might contribute to greater safety and efficacy when applied clinically. The presented approach appears to be promising, especially in difficult settings, provided that in vivo data support these initial results.

• Pathological upstaging detected in radical cystectomy procedures is associated with a significantly worse tumour-specific survival rate for patients with clinical T1 urothelial carcinoma of the urinary bladder.

  Authors: Matthias May, Patrick J Bastian, Sabine Brookman-May, Maximilian Burger, Christian Bolenz, Lutz Trojan, Maurice S Michel, Edwin Herrmann, Christian Wülfing, Arne Tiemann [......] Derya Tilki, Wolf F Wieland, Christian Gilfrich, Thomas Höfner, Markus Hohenfellner, Axel Haferkamp, Jan Roigas, Mario Zacharias, Sven Gunia, Hans-Martin Fritsche

  Scandinavian journal of urology and nephrology. 03/2011; 45(4):251-7.

  Due to their variable oncological course, clinical stage T1 (cT1) urothelial carcinomas of the bladder (UCBs) are the subject of controversial discussion with regard to indication for radicalDue to their variable oncological course, clinical stage T1 (cT1) urothelial carcinomas of the bladder (UCBs) are the subject of controversial discussion with regard to indication for radical cystectomy (RC).This study aimed to evaluate the frequency and prognosis of upstaging in patients undergoing RC due to UCB. Clinical and pathological records of 607 patients, having undergone RC for treatment of UCB in cT1N0M0, were summarized in a multi-institutional database. Cancer-specific survival (CSS) and overall survival (OS) rates were calculated. A multivariable prognostic model predicting the possibility of an upstaging in RC specimens was developed based on clinical information. In 210patients (35%) an upstaging (> pT1 and/or pN+) was detected in the RC specimen. Five-year CSS was 86%, 78%, 60%and 34%, respectively, for tumour stages < pT2N0 (n = 397), pT2N0 (n = 78), > pT2N0 (n = 63)and pN+ (n = 69) (p < 0.001). In a multivariable Cox regression model, pN stage, pT stage and lymphovascular invasion (LVI) revealed an independent influence on CSS (OS: pN, pT, age). An upstaging of cT1 tumours was enhanced by the criteria of G3 tumour grading and absent Tis in the transurethral resection of the bladder (TURB)specimen. Detection of LVI in RC specimens was also independently associated with an upstaging and, therefore, is recommended as a relevant prognostic parameter for the histopathological evaluation of TURB specimens. More than one-third of patients with cT1 tumours had an upstaging that was associated with significant prognosis deterioration. Further valid markers are required for an early identification of these patients. LVI represents such a criterion and, therefore, should be evaluated in prospectively designed trials with accurate histopathological assessment of TURB specimens.

• Treatment decision-making in localized prostate cancer: why patients chose either radical prostatectomy or external beam radiation therapy.

  Authors: Andreas Ihrig, Monika Keller, Mechthild Hartmann, Jürgen Debus, Jesco Pfitzenmaier, Boris Hadaschik, Markus Hohenfellner, Wolfgang Herzog, Johannes Huber

  BJU international. 03/2011; 108(8):1274-8.

  • To evaluate patients' treatment decision-making for localized prostate cancer. • To determine their willingness to participate in a randomized controlled trial (RCT) comparing radical prostatectomy• To evaluate patients' treatment decision-making for localized prostate cancer. • To determine their willingness to participate in a randomized controlled trial (RCT) comparing radical prostatectomy (RP) with external beam radiation therapy (EBRT). • We investigated 31 patients with localized prostate cancer who had opted for either RP (n= 18) or EBRT (n= 13) as primary therapy. • A semi-structured interview and a short questionnaire were completed a few days after the start of treatment, covering all aspects of treatment decision. • Most patients wanted to decide on their treatment together with their physician and were generally satisfied with the information provided. Internet resources were used more frequently by the RP group (14/18 patients) than by the EBRT group (three of 13 patients, P < 0.01). • Physicians' advice and other patients' experiences were highly influential in the final treatment decisions. • Patients deciding on RP were younger and their personal beliefs were their typical decision criteria (RP, six of 18 patients vs EBRT, none; P= 0.03). By contrast, possible treatment-related side-effects were a major concern for patients choosing EBRT (RP, two of 18, vs EBRT, seven of 14; P= 0.02). • Only two patients (of 31, 6%) would have consented to random assignment to either RP or EBRT, while six (19%) patients were not averse. • Patients are satisfied with the information provided and with their decision-making process. • Typical modes of reasoning can be found and mainly consist of personal beliefs in patients choosing RP and fear of treatment related side-effects in those choosing EBRT. • According to the sample, the participation rate for a RCT comparing RP to EBRT would not exceed 25% without further efforts.

• Selective transarterial embolization for posttraumatic renal hemorrhage: a second try is worthwhile.

  Authors: Johannes Huber, Sascha Pahernik, Peter Hallscheidt, Christof M Sommer, Nina Wagener, Gencay Hatiboglu, Axel Haferkamp, Markus Hohenfellner

  The Journal of urology. 03/2011; 185(5):1751-5.

  Selective percutaneous transarterial embolization has proved to be effective, safe treatment for posttraumatic renal hemorrhage but inefficacious procedures often lead to nephrectomy. Thus, theSelective percutaneous transarterial embolization has proved to be effective, safe treatment for posttraumatic renal hemorrhage but inefficacious procedures often lead to nephrectomy. Thus, the success rate of transarterial embolization should be maximized. We retrospectively investigated the clinical success rate of transarterial embolization for posttraumatic bleeding. Study inclusion criteria were imaging evidence and clinical signs of hemorrhage or a hemoglobin decrease of more than 2 gm/dl in urological cases. We excluded spontaneous bleeding from analysis. A total of 21 patients with a median age of 66 years (range 12 to 78) met study inclusion criteria. Etiology was blunt trauma in 3 cases (14%), stab wound in 1 (5%) and an iatrogenic cause in 17 (81%). In 2 patients an active bleeding site could not be detected during selective angiography. Transarterial embolization was done in 19 patients and led to primary clinical success in 12 (63%), including 2 with grade V parenchymal injury. In 6 of 7 cases (86%) in which primary treatment failed transarterial embolization was repeated. It resulted in clinical success in 4 of 6 patients (67%) with equal efficiency (p =1). Three patients (16%) who could not be sufficiently treated with transarterial embolization underwent nephrectomy. When conservative measures fail and clinical symptoms or a relevant hemoglobin decrease occur, transarterial embolization should be considered. Since the success rate is equally high for initial and repeat interventions, re-intervention is justified when the clinical course allows.

• Robot-assisted prostatectomy: the new standard of care.

  Authors: Gencay Hatiboglu, Dogu Teber, Markus Hohenfellner

  Langenbeck's archives of surgery / Deutsche Gesellschaft für Chirurgie. 02/2011; 397(3):343-52.

  INTRODUCTION: Robot-assisted radical prostatectomy (RARP) has first been performed in 2000 and has since then become a widespread and often performed therapy option for surgical treatment of prostateINTRODUCTION: Robot-assisted radical prostatectomy (RARP) has first been performed in 2000 and has since then become a widespread and often performed therapy option for surgical treatment of prostate cancer. The purpose of this review was to highlight the current clinical concepts for radical prostatectomy. DISCUSSION AND CONCLUSIONS: Actual literature search was performed in PubMed database and reviewed. Different surgical techniques for RARP are presented. Oncologic and functional outcomes of RARP are discussed and compared to radical retropubic prostatectomy. In conclusion, RARP has equal oncologic and functional outcome in localized prostate cancer. RARP as a less invasive treatment option for patients with localized prostate cancer should be considered as a new standard of care by now.