Alexander Karl

Ludwig-Maximilian-University of Munich, München, Bavaria, Germany

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Publications (99)192.58 Total impact

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    ABSTRACT: High-dose local stereotactic radiosurgery (SRS) has been performed in selected patients to improve local tumor control and overall survival. Here we report on patients with renal tumors who were treated with single-fraction robotic SRS.
    The Journal of urology. 08/2014;
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    ABSTRACT: Non-muscle-invasive bladder cancer (NMIBC) is associated with a high recurrence risk, partly because of the persistence of lesions following transurethral resection of bladder tumour (TURBT) due to the presence of multiple lesions and the difficulty in identifying the exact extent and location of tumours using standard white-light cystoscopy (WLC). Hexaminolevulinate (HAL) is an optical-imaging agent used with blue-light cystoscopy (BLC) in NMIBC diagnosis. Increasing evidence from long-term follow-up confirms the benefits of BLC over WLC in terms of increased detection and reduced recurrence rates.
    European urology. 07/2014;
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    ABSTRACT: Introduction: The purpose of this study was to evaluate and compare complications after radical cystectomy in patients aged ≥75 years. Materials and Methods: 251 patients aged 75-95 years (median 79) underwent radical cystectomy between 2000 and 2012 at four institutions. The patients were divided into two groups: ≥75-84 years of age (group 1) versus ≥85 years of age (group 2). Comorbidities, body mass index, and complications were obtained retrospectively, except at the Central Hospital of Bolzano and Weill Cornell Medical Center, which collected data prospectively. Cancer-specific survival, overall mortality, hospital stay, clinical outcome and complications were assessed. Complications were categorized using the Clavien-Dindo classification reporting system. The mean follow-up was 21 months. Results: The median hospital stay was 17 (2-91) days. Perioperative Clavien-Dindo grade ≥III complications were seen in 24.1% (48/199) of group 1 patients and 19.2% (10/52) of group 2 patients (p = 0.045). 30- and 90-day mortality was 4.5 and 13.5% in group 1 and 6.5 and 32.3% in group 2, respectively. Only the 90-day mortality rate was statistically significant (p < 0.05) between the two groups. The 3-year overall survival was 40% in group 1 and 34% in group 2. The 3-year cancer-specific survival was 52% in group 1 and 50% in group 2. Conclusions: We evaluated a large series of elderly (≥75 years) patients undergoing radical cystectomy at four institutions. Comparing patients aged ≥75-84 and ≥85 years revealed no significant difference in complications, 30-day mortality, overall and cancer-specific survival rates. Only 90-day mortality rates were significantly higher in the ≥85-year-old patients. © 2014 S. Karger AG, Basel.
    Urologia Internationalis 06/2014; · 1.07 Impact Factor
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    ABSTRACT: In 2006, the German Testicular Cancer Study Group initiated an extensive evidence-based national second-opinion network to improve the care of testicular cancer patients. The primary aims were to reflect the current state of testicular cancer treatment in Germany and to analyze the project's effect on the quality of care delivered to testicular cancer patients. A freely available internet-based platform was developed for the exchange of data between the urologists seeking advice and the 31 second-opinion givers. After providing all data relevant to the primary treatment decision, urologists received a second opinion on their therapy plan within <48 h. Endpoints were congruence between the first and second opinion, conformity of applied therapy with the corresponding recommendation and progression-free survival rate of the introduced patients. Significance was determined by two-sided Pearson's χ2 test. A total of 1,284 second-opinion requests were submitted from November 2006 to October 2011, and 926 of these cases were eligible for further analysis. A discrepancy was found between first and second opinion in 39.5% of the cases. Discrepant second opinions led to less extensive treatment in 28.1% and to more extensive treatment in 15.6%. Patients treated within the framework of the second-opinion project had an overall 2-year progression-free survival rate of 90.4%. Approximately every 6th second opinion led to a relevant change in therapy. Despite the lack of financial incentives, data from every 8th testicular cancer patient in Germany were submitted to second-opinion centers. Second-opinion centers can help to improve the implementation of evidence into clinical practice.
    Oncology Reports 04/2014; · 2.30 Impact Factor
  • European Urology Supplements 01/2014; 13(1):e46. · 2.16 Impact Factor
  • MMW Fortschritte der Medizin 12/2013; 155(21-22):40-2.
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    ABSTRACT: ITIH5 has been associated with tumour suppression in various cancers. However, its putative role in bladder cancer is completely unknown. Therefore, we initiated a study analysing ITIH5 expression as well as its prognostic and functional impact on human urothelial cancers (UC). Expression analysis showed a clear downregulation of ITIH5 mRNA in 61% (n=45) of UC, especially in muscle-invasive tumours (p<0.001). ITIH5 loss in UC was further evident on protein level (65.5%, n=55) as detected by immunohistochemistry. DNA methylation analysis demonstrated tumour-specific ITIH5 promoter methylation in 50% of papillary none-invasive pTa (n=30) and 68% of invasive (n=28) UC. Aberrant ITIH5 promoter methylation in bladder tumours was tightly linked (p<0.001) with loss of ITIH5 mRNA expression, which was furthermore functionally confirmed by demethylation analysis in cell lines. Pyrosequencing analysis revealed that ITIH5 promoter hypermethylation was closely associated with progressive bladder cancers. Subsequently, a large cohort (n=120) of clinically challenging pT1 high grade UC was analysed for ITIH5 expression. Of clinical significance, we found an association between loss of ITIH5 expression and unfavourable prognosis of UC patients without distant metastasis at first diagnosis (recurrence-free survival; hazard ratio: 4.35, p=0.048). Functionally, ITIH5 re-expression in human RT112 bladder cancer cells led to both suppression of cell migration and inhibition of colony spreading. Hence, we provide evidence that downregulation of ITIH5 by aberrant DNA hypermethylation may provoke invasive phenotypes in human bladder cancer. Moreover, ITIH5 protein might become a prognostic biomarker for relapse risk stratification in high grade UC patients.
    Carcinogenesis 11/2013; · 5.64 Impact Factor
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    ABSTRACT: Purpose: To report postoperative health-related quality of life (HRQoL) and patients' subjective evaluations of open pyeloplasty (OP) and retroperitoneoscopic pyeloplasty (RP) and influences on preoperative counselling. Methods: 107 patients (age 16-80 years, mean 31.5) with symptomatic primary ureteropelvic junction obstruction who underwent OP (32) or RP (75) were evaluated prospectively. HRQoL was evaluated using Short Form 36 (SF-36) questionnaires with 1 year follow-up. Operative outcomes were evaluated using a self-designed questionnaire regarding cosmetic outcomes, objective postoperative/current pain, convalescence and return to work. Results: The mean operative time was 174.4 vs. 161.4 min for RP versus OP, respectively, without intraoperative complications/conversions. There was an advantage for RP - except for two domains - without significance in any of the eight SF-36 domain scores. An advantage favouring RP in all aspects of the second questionnaire with significance in four aspects (cosmetic results, scar length, pain and convalescence) was found. Five weeks postoperatively, 58.7% (RP) vs. 25.8% (OP) were fully convalescent compared to 87.0% (RP) vs. 71.0% (OP) at 8 weeks. Similarly, 58.7 vs. 45.1% returned work 5 weeks postoperatively while 93.5 vs. 74.2% did so after 8 weeks, respectively. The small sample size, more questions on satisfaction/regret and mixed design are the main study limitations. Conclusion: RP provides the same functional results beside earlier convalescence, better HRQoL and patients' convenience with surgery, which favours its inclusion in preoperative counselling providing patients with realistic postoperative expectations.
    Urologia Internationalis 09/2013; · 1.07 Impact Factor
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    ABSTRACT: Early recovery after surgery (ERAS) concepts have gained wide acceptance in various surgical specialities. However, limited data are available for radical cystectomy. A new ERAS concept was compared to a more conservative regimen (CR) in patients undergoing radical cystectomy for bladder cancer. 101 consecutive patients were prospectively randomized to ERAS (n=62) or CR (n=39) (intended randomization ERAS:CR=2:1). Primary endpoints were differences in quality of life; secondary endpoints included postoperative morbidity, demand of analgesics, time spent at intermediate care unit, mobility and number of gastrointestinal events during hospital stay. Quality of life parameters, as measured by the EORTC-QLQ-30, did not change significantly between day 3, 7 and at discharge in CR whereas a significant improvement was observed in the ERAS group. Postoperative morbidity was lower for ERAS regarding wound healing disorders (p=0.006), fever (0.004), and thrombosis (0.027). Demand for analgesics was significantly lower for ERAS; the amount of consumed food in relation to the amount of offered food was significantly higher for ERAS as soon as day 3 (p=0.02). Time spent at intermediate care unit was significantly shorter for ERAS (p<0.001). There were no significant differences with respect to gastrointestinal events. Main limitations of this study are the lack of long term data as well as the single center approach. ERAS in patients after radical cystectomy appears to have significant benefits as compared to a conservative regimen with regard to postoperative morbidity, quality of life, use of analgesics and time spent at the ICU.
    The Journal of urology 08/2013; · 4.02 Impact Factor
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    ABSTRACT: Cystoscopy and urinary cytology are standard tools in the diagnostics of urothelial cancer of the urinary bladder; however, cystoscopy is invasive and urinary cytology lacks accuracy for the diagnosis of low grade tumors. More recently several alternative urinary test systems were developed with the aim to make the diagnostics of urothelial tumors more reliable; however, in general all protein-based point of care test systems have a high rate of false positive test results, especially in patients with benign disorders. Fluorescence in situ hybridization, which is highly sensitive and specific, may be a reasonable supplement to the diagnostic spectrum in patients after instillation therapy or bladder replacement. Additionally, there are several new test systems which still need to be tested in large clinical studies with respect to diagnostic accuracy.
    Der Urologe 06/2013; · 0.46 Impact Factor
  • European Urology 06/2013; · 10.48 Impact Factor
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    ABSTRACT: BACKGROUND: Studies on hexaminolevulinate (HAL) cystoscopy report improved detection of bladder tumours. However, recent meta-analyses report conflicting effects on recurrence. OBJECTIVE: To assess available clinical data for blue light (BL) HAL cystoscopy on the detection of Ta/T1 and carcinoma in situ (CIS) tumours, and on tumour recurrence. DESIGN, SETTING, AND PARTICIPANTS: This meta-analysis reviewed raw data from prospective studies on 1345 patients with known or suspected non-muscle-invasive bladder cancer (NMIBC). INTERVENTION: A single application of HAL cystoscopy was used as an adjunct to white light (WL) cystoscopy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We studied the detection of NMIBC (intention to treat [ITT]: n=831; six studies) and recurrence (per protocol: n=634; three studies) up to 1 yr. DerSimonian and Laird's random-effects model was used to obtain pooled relative risks (RRs) and associated 95% confidence intervals (CIs) for outcomes for detection. RESULTS AND LIMITATIONS: BL cystoscopy detected significantly more Ta tumours (14.7%; p<0.001; odds ratio [OR]: 4.898; 95% CI, 1.937-12.390) and CIS lesions (40.8%; p<0.001; OR: 12.372; 95% CI, 6.343-24.133) than WL. There were 24.9% patients with at least one additional Ta/T1 tumour seen with BL (p<0.001), significant also in patients with primary (20.7%; p<0.001) and recurrent cancer (27.7%; p<0.001), and in patients at high risk (27.0%; p<0.001) and intermediate risk (35.7%; p=0.004). In 26.7% of patients, CIS was detected only by BL (p<0.001) and was also significant in patients with primary (28.0%; p<0.001) and recurrent cancer (25.0%; p<0.001). Recurrence rates up to 12 mo were significantly lower overall with BL, 34.5% versus 45.4% (p=0.006; RR: 0.761 [0.627-0.924]), and lower in patients with T1 or CIS (p=0.052; RR: 0.696 [0.482-1.003]), Ta (p=0.040; RR: 0.804 [0.653-0.991]), and in high-risk (p=0.050) and low-risk (p=0.029) subgroups. Some subgroups had too few patients to allow statistically meaningful analysis. Heterogeneity was minimised by the statistical analysis method used. CONCLUSIONS: This meta-analysis confirms that HAL BL cystoscopy significantly improves the detection of bladder tumours leading to a reduction of recurrence at 9-12 mo. The benefit is independent of the level of risk and is evident in patients with Ta, T1, CIS, primary, and recurrent cancer.
    European Urology 04/2013; · 10.48 Impact Factor
  • A Karl, C Stief, D Zaak
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    ABSTRACT: The diagnosis and follow-up of bladder cancer is based on the so-called golden standard of urine cytology and white light endoscopy. In recent years fluorescence endoscopy, also known as photodynamic diagnosis (PDD), of the urinary bladder has become more and more popular. The rising interest in this procedure becomes clear when looking at the current literature. Nowadays, there are studies on PDD from all over Europe and the USA. This article gives an up to date review of these new studies and shows new developments in the outpatient use of PDD.
    Der Urologe 03/2013; · 0.46 Impact Factor
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    ABSTRACT: Introduction As international guidelines recommend best practices regarding staging of incident bladder cancer, we determined the adherence to such recommendations in the US performing a large retrospective database analysis. Patients and Methods Patients with the diagnosis of urothelial cancer were identified in the SEER Medicare database between 1992 and 2007. Staging procedures were identified and analyzed. As reference for published recommendations, we used the AUA, EAU, and NCCN guidelines. Based on these sources, recommended staging of bladder cancer was analyzed. Of all 56,130 subjects, 6,148 (10.9%) had a cytological examination, 29,677 (52.9%) a standard urinalysis, 2,882 (5.1%) an intravenous pyelogram, 6,950 (12.4%) a retrograde pyelogram and 8,145 (14.5%) a CT/MRI examination. Results There was a significant trend over the years to a higher use of cytology, standard urinalysis and CT/MRI examinations. We observed a significant trend to a lower rate of intravenous pyelograms and a stable use of retrograde pyelograms. The limitation of our study is that claims data are designed for payment processing, not quality measurement. Conclusion Despite published recommendations on initial diagnosis of bladder cancer, our data show that less than half of the included patients received all the elements thought to be required for an initial diagnosis of bladder cancer as recommended by guidelines. Greater adherence to recommended guidelines may ensure optimal treatment strategies. Appropriate treatment is critical to patient outcomes, as evidence based therapeutic management can only be practiced if an accurate assessment of the disease takes place at the time of initial diagnosis.
    Clinical Genitourinary Cancer 01/2013; · 1.43 Impact Factor
  • A. Karl, C. Stief, D. Zaak
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    ABSTRACT: Die Diagnostik und Nachsorge von Harnblasenkarzinomen basieren seit vielen Jahren auf dem Goldstandard der urinzytologischen Untersuchung in Verbindung mit der Weißlichtzystoskopie. In den letzten Jahren hat die photodynamische Diagnostik (PDD) der Harnblase in Deutschland aber auch in anderen europäischen Ländern zunehmend an Bedeutung gewonnen, was u. a. an der stark gestiegenen Anzahl an Publikationen zu diesem Thema deutlich wird. Unser Beitrag soll nun eine Übersicht über die aktuellen Studienergebnisse rund um die PDD geben sowie mögliche neue Entwicklungen beim Einsatz der PDD aufzeigen.
    Der Urologe 01/2013; 52(4). · 0.46 Impact Factor
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    ABSTRACT: Die Standardverfahren bei der Diagnostik des Urothelkarzinoms der Harnblase sind die Zystoskopie und die Urinzytologie. Doch die Zystoskopie ist ein invasives Verfahren und die Zytologie ist unsicher in der Diagnostik von Low-grade-Karzinomen. Daher wurden in den letzten Jahren eine ganze Reihe verschiedener uringebundener Tumortestverfahren entwickelt um die Diagnose dieses häufigen Tumors zu vereinfachen. Insgesamt leiden aber die kommerziell erhältlichen Schnelltestverfahren unter einer hohen Rate an falsch-positiven Ergebnissen insbesondere beim Vorliegen benigner Erkrankungen. Ein sinnvoller Zusatz zur Standarddiagnostik kann hingegen die Fluoreszenz-in-situ-Hybridisierung darstellen, die hoch spezifisch ist und auch in Situationen nach Instillationstherapie oder Harnableitung eine zuverlässige Tumordiagnostik ermöglicht. In der präklinischen Erprobung findet sich eine Reihe neuer Verfahren, deren klinischer Wert aber noch in größeren Studien überprüft werden muss.
    Der Urologe 01/2013; 52(7). · 0.46 Impact Factor
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    ABSTRACT: PURPOSE: Muscle invasive bladder cancer can be found predominantly in elderly people with a high likelihood of suffering from concomitant diseases; especially in these patients, the risks associated with general anaesthesia during radical cystectomy can be the limiting factor of performing an otherwise indicated radical operation. To overcome this limitation, we analysed the feasibility of performing radical cystectomy in exclusive spinal and/or epidural anaesthesia. METHODS: Between March and June 2010, nine patients underwent radical cystectomy in exclusive spinal and/or epidural anaesthesia. These patients were either not willing or unfit to undergo radical cystectomy in general anaesthesia. A continent urinary diversion (ileum neobladder) and an ileum-conduit were performed in five patients and four patients, respectively. The feasibility of radical cystectomy in regional anaesthesia was tested using a variety of parameters. RESULTS: All nine procedures could be performed under strict regional anaesthesia. Mean operation time was 206 min (range 146-265 min), mean intraoperative blood loss was 622 ml (range 200-1,500 ml), mean postoperative time at intermediate care was 1 day (range 0-3 days) and mean length of hospital stay was 21.8 days (range 17-26 days). Analgesics of the WHO class I, II and III were applied for 5.7, 1.2 and 2.8 days mean, respectively. CONCLUSION: Performance of radical cystectomy in exclusive spinal and/or epidural anaesthesia is feasible and can be considered particularly in those patients who would be otherwise unfit to undergo radical cystectomy in general anaesthesia. This new operative and anaesthesiological concept could also play an important role in new fast track regimens.
    World Journal of Urology 07/2012; · 2.89 Impact Factor
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    ABSTRACT: We assessed the impact of hexaminolevulinate fluorescence cystoscopic detection of papillary, nonmuscle invasive bladder cancer on the long-term recurrence rate. Long-term followup was assessed in 551 participants enrolled in a prospective, randomized study of fluorescence cystoscopy for Ta or T1 urothelial bladder cancer. In the original study 280 patients in the white light cystoscopy group and 271 in the fluorescence cystoscopy group were followed with cystoscopy for 3, 6 and 9 months after initial resection or until recurrence. A study extension protocol was done for long-term followup of these patients. Followup information was obtained for 261 of the 280 patients (93%) in the white light group and 255 of the 271 (94%) in the fluorescence group. Median followup in the white light and fluorescence groups was 53.0 and 55.1 months, and 83 (31.8%) and 97 patients (38%) remained tumor free, respectively. Median time to recurrence was 9.4 months in the white light group and 16.4 months in the fluorescence group (p = 0.04). The intravesical therapy rate was similar in the 2 groups (46% and 45%, respectively). Cystectomy was done in 22 of 280 cases (7.9%) in the white light group and in 13 of the 271 (4.8%) in the fluorescence group (p = 0.16). Hexaminolevulinate fluorescence cystoscopy significantly improves long-term bladder cancer time to recurrence with a trend toward improved bladder preservation.
    The Journal of urology 05/2012; 188(1):58-62. · 4.02 Impact Factor
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    ABSTRACT: OBJECTIVES: To determine accuracy of upper tract cytology and ureteroscopic biopsy according to the 2004 World Health Organization (WHO) classification in predicting the correct tumor grade in patients with urothelial cancer of the upper urinary tract (UUT-UC). METHODS: Pathology reports of 77 nephroureterectomy specimens were retrospectively analyzed for tumor grade and compared with preoperatively gained cytology and ureteroscopic biopsy results. For analysis, the 2004 WHO classification was used. RESULTS: Overall sensitivity of cytology and biopsy in diagnosis of UUT-UC was 64% and 74%, respectively. Accuracy of cytology and biopsy in predicting high grade cancer was 53% and 58%, respectively. Combination of cytology and biopsy could improve sensitivity (84%) and accuracy (68%), but even for this combination, 15% of high grade tumors were misinterpreted as low grade cancer. CONCLUSION: Our results show only limited accuracy for preoperative cytology and ureterorenoscopically performed biopsies in the prediction of the correct tumor grading of an UUT-UC. Therefore, we suggest the use of additional diagnostic procedures before the decision for definitive surgical treatment in patients with UUT-UC is made.
    Urologic Oncology 01/2012; · 3.65 Impact Factor
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    ABSTRACT: OBJECTIVES: To assess the power of multi-detector row computerized tomography (MDCT) in daily routine as a basic staging procedure for the decision on local treatment of patients with bladder cancer. PATIENTS AND METHODS: We retrospectively analysed 276 patients who had undergone radical cystectomy between 2004 and 2008 and correlated the MDCT findings with pathological findings, number of removed lymph nodes and type of urinary diversion. RESULTS: Accuracy of MDCT in predicting pathological tumour stage was 49% (kappa coefficient, 0.23; P < 0.001). Overstaging occurred in 23.4%, and understaging occurred in 24.7%. Accuracy in predicting lymph node metastases was 54% (kappa coefficient, 0.04; P = 0.297). Overstaging and understaging occurred in 8.3 and 29.4%, respectively. Significantly more ileal conduits were performed in patients with high postoperative pathological tumour stages (P = 0.04) and positive lymph nodes (P = 0.013). In contrast, there was no correlation between preoperative CT tumour/nodal stage and the number of removed lymph nodes (P = 0.44 and P = 0.732, respectively), and between preoperative tumour stage and type of urinary diversion (P = 0.126). CONCLUSIONS: MDCT as a preoperative staging procedure has a low accuracy in predicting the correct tumour and nodal stage, and therefore, it has little impact on decision-making for local treatment of muscle-invasive bladder cancer during radical cystectomy.
    World Journal of Urology 12/2011; · 2.89 Impact Factor

Publication Stats

784 Citations
192.58 Total Impact Points

Institutions

  • 2005–2014
    • Ludwig-Maximilian-University of Munich
      • Department of Urology
      München, Bavaria, Germany
  • 2009–2013
    • University of California, San Francisco
      • • Department of Urology
      • • Division of Hospital Medicine
      San Francisco, California, United States
  • 2010
    • University of Florida
      • Department of Urology
      Gainesville, Florida, United States
    • Vanderbilt University
      Nashville, Michigan, United States
  • 2007–2010
    • Technische Universität München
      • Institute of Radiology
      München, Bavaria, Germany
  • 2008
    • RWTH Aachen University
      • Department of Urology
      Aachen, North Rhine-Westphalia, Germany
  • 2006
    • Universität Regensburg
      • Department of Urology
      Ratisbon, Bavaria, Germany