[LOH (late-onset hypogonadism) or the "aging male"]. / LOH (late onset hypogonadism) oder "aging male".

Due to lacking evidence of the data about testosterone deficiency of the aging male or LOH (late-onset hypogonadism), this subject is still a challenge for urologists, endocrinologists, and dermatologists or andrologists. This challenge faces basic research as well as clinical investigations. We have to accept responsibility for solving this challenge to better understand and better treat our patients beyond the scope of current guidelines.

Surgical anatomy of the puboprostatic complex with special reference to radical perineal prostatectomy.

OBJECTIVE: To investigate the retropubic space and attachments of the prostate and urethra, with special reference to radical perineal prostatectomy. MATERIALS AND METHODS: Anatomical relationships were assessed intraoperatively in 60 patients, and in five cadavers after preparing the dorsal vein complex with coloured latex. Cross-sections of the area of interest were evaluated by microscopy. RESULTS: The puboprostatic (pubovesical) ligaments could be clearly distinguished from the median part of the puboprostatic complex continuous with the urethral suspensory mechanism. The dorsal vein complex is integrated into this fibromuscular attachment of the prostate and male urethra. During the perineal approach, dissection in this region follows the so-called avascular plane. CONCLUSION: With this new insight into the anatomical relationships the nomenclature derived from radical retropubic prostatectomy could be mirrored. In radical perineal prostatectomy, both the urethral suspensory mechanism and the dorsal vein complex can be preserved.

Are adverse effects of sildenafil also caused by inhibition of diamine oxidase?

BACKGROUND: Sildenafil citrate (Viagra), a drug used to treat erectile dysfunctions, causes adverse reactions such as headache, flushing or nasal congestion. Sildanefil's potency as inhibitor of diamine oxidase was investigated, as side effects may also be induced by histamine itself due to an impaired histamine metabolism. METHODS: Placental diamine oxidase inhibition experiments were performed with consecutive dilutions of sildenafil citrate (10(-5) to 10(-9) mol/l). In 9 male volunteers in vivo diamine oxidase inhibition was investigated after taking 100 mg sildenafil (Viagra). RESULTS: Sildenafil citrate did not inhibit placental diamine oxidase either in vitro or in vivo. However, infusion of 300 mg of cimetidine inhibited diamine oxidase activity by 27 +/- 7% 15 min after infusion, demonstrating that drugs may inhibit diamine oxidase in vivo. CONCLUSION: As side effects of sildenafil are not caused due to inhibition of diamine oxidase, sildenafil citrate seems to be harmless for patients suffering from histamine intolerance.

Presence of PGE1 binding determines the erectile response to PGE1.

The clinical benefit of PGE1 in erectile dysfunction in men is well proven, while other species including non-human primates show almost no response. The reason for that difference is still unclear. We examined PGE1 binding in human surgical material (n=27) and from transsexual surgery (n=7) as well as rhesus (n=10) and cynomolgus monkeys (n=8) corpus cavernosum tissue. Erection was judged after intracavernous injection of PGE1 in men (10 microg) and in monkeys (5 microg). Human corpus cavernosum shows high- (binding capacity 24.7+/-3.3 pmol/mg protein) and low-affinity (binding capacity 77.4+/-7.3 pmol/mg protein) PGE1 binding sites. Oestrogen (3 mg/day) for more than one month before transsexual surgery decreases receptor density significantly. In rhesus and cynomolgus monkeys no high-affinity binding could be detected, while they respond on PGE1 with slight tumescence only. These findings indicate a significant correlation between corpus cavernosum PGE1 receptor density and the erectile response.

Accumulation of platelets as a key mechanism of human erection.

In this study, the role of platelets in the human erectile response was assessed. Twenty patients with erectile dysfunction were studied by means of (111)In-oxine-platelets and blood pool imaging using 99mTc. Seventeen patients received intracavernously prostaglandin E1, and three patients received papaverine together with phentolamine. In patients who responded with erection, an increase by between 16 to 137% platelets/ml and a rapid platelet accumulation in the penis during the initial phase of erection were observed. In patients without erection, no change in local platelet concentration occurred. It is likely that platelets play a major role in human erection, probably by temporary activation, thereby regulating venous outflow.

Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German Urologic Association.

PURPOSE: The centers of the laparoscopy working group of the German Urologic Association collected data to prove the efficacy, safety and reproducibility of laparoscopic nephrectomy. MATERIALS AND METHODS: At 14 centers 482 laparoscopic nephrectomies have been performed until December 1996 via a transperitoneal approach in 344 (71%) and a retroperitoneal approach in 138 (29%). All 482 laparoscopic nephrectomies were performed by a total of 20 surgeons with an average of 24 procedures per surgeon (range 4 to 105). The indications for nephrectomy were benign renal pathology in 444 patients (92%), including renovascular disease in 28%, hydronephrosis in 20%, reflux nephropathy in 15%, chronic pyelonephritis in 12%, end stage nephrolithiasis in 11%, renal dysplasia in 4% and renal tuberculosis in 1%. Of the remaining 38 patients (8%) laparoscopic radical nephrectomy was performed for renal cell carcinoma in 5% and for upper tract transitional cell carcinoma in 3%. RESULTS: Operating time depended mainly on the pathology of the kidney (that is small dysplastic organ versus large hydronephrosis) and the learning curve of the surgeon. However, the average operating time did not vary significantly among the different centers (maximum 277.6 and minimum 81.9 minutes). Intraoperative or perioperative complications were noted in 29 patients (6.0%), including bleeding in 22 (4.6%), bowel injury in 3, hypercarbia in 2 and pleura lesion in 1 and pulmonary embolism in 1. The conversion rate was 10.3% (bleeding, bowel injury, difficult dissection), including 4 patients with renal tuberculosis, 2 with xanthogranulomatous nephritis, and 1 each following renal trauma and embolization. The re-intervention rate was 3.4% due to bleeding in 6 cases, abscess formation in 3, intestinal stenosis in 2 and a pancreatic fistula and port hernia in 1. Mean hospital stay was 5.4 days. CONCLUSIONS: Laparoscopic nephrectomy has become a well established procedure in those urology departments focusing on laparoscopy. The indications and results are reproducible at these centers. However, for patients with severe perinephritis (that is renal tuberculosis, xanthogranulomatous nephritis, posttraumatic atrophy) a higher likelihood of open conversion must be considered.

Experience in renal autotransplantation: analysis of a clinical series.

OBJECTIVE: To determine the benefit of renal autotransplantation in selected patients with either renovascular lesions, renal or urothelial carcinomas or other disorders of the urinary collecting system. PATIENTS AND METHODS: Between 1977 and 1994, 12 patients underwent renal autotransplantation, six involving renovascular hypertension, two involving tumours of the renal parenchyma, two with urothelial tumours and two with long ureteric stenoses. Pre-operative renal function was normal in six patients and impaired in five. One patient was on haemodialysis. Five patients had a solitary kidney and four patients had functionally solitary kidneys. The follow-up period ranged from 1 to 93 months (mean 34.9). RESULTS: Post-operatively, six patients had normal kidney function (serum creatinine < or = 12 mg/L), five patients had impaired renal function (creatinine content < or = 26 mg/L) and one patient was on haemodialysis due to arterial graft thrombosis. Serum creatinine levels improved in four patients and were stable in another four. Renal function deteriorated in three patients and one patient required a graft-nephrectomy. Immediate post-operative complications included arterial thrombosis in one patient, perirenal haematoma in two, pulmonary oedema in one and severe intra-operative bradycardia requiring a transient cardiac pacemaker in one. CONCLUSION: Renal autotransplantation represents an effective alternative treatment with good long-term results for selected patients with long ureteric lesions and renovascular disorders. It is also an effective method for patients with urological malignancies, especially those with solitary kidneys where the maintenance of renal function is of major concern.

[Urolithiasis in children]. / Urolithiasis bei Kindern.

Urolithiasis is rare in childhood (about 1%) and commonly associated with urinary tract infection. Like in adults ESWL is the minimally invasive treatment and therefore primary therapeutic approach. However, the passage of stone debris is less complicated than in adults and auxiliary measures are seldom needed. There is no evidence of soft tissue damage after ESWL, but in aspect of the growing organ lithotriptors with small focal zone and ultrasound location system are preferable. Obstructive anatomical abnormalities, if so, must be treated simultaneously. For prevention a strict antibiotic (longterm) therapy, according repeat antibiograms, and exclusion of metabolic disease are essential. Medication as well as special diets must be handled carefully or avoided as they might induce growth disorders.

Quantification of prostaglandin E1 receptors in cavernous tissue of men, monkeys and dogs.

Prostaglandin E1 (PGE1) has been shown to relax the muscles of the corpora cavernosa and inhibit spontaneous activity, and clinical trials have proved its safety and effectiveness when given intracavernously to induce erection. Through use of a specific PGE1 receptor binding assay, we undertook this study to quantify its receptor density and measure binding affinity. The cavernous tissue of normal and impotent men as well as that of monkeys and dogs was studied in an attempt to understand their different responses to the intracavernous injection of PGE1. Our results showed a lower receptor density in impotent men than in normal men and monkeys and a complete absence of receptors in dogs. These findings correlated well with the clinical response to intracavernous injection of PGE1.

Percutaneous endoscopic cholecystolithotripsy. Work in progress.

In spite of long-term adjunctive oral dissolution therapy, residual gallstones have been reported in up to 50% of gallstone patients 3 months after extracorporeal shock-wave lithotripsy. Six women and five men, aged 31-75 years, underwent percutaneous endoscopic cholecystolithotripsy between April 1988 and October 1988. The gallbladder was punctured by means of an anterior transperitoneal approach. The tract was dilated, and gallstones were removed with a modified 21-F cholecystoscope under direct visual inspection. Calculi too large for extraction were disintegrated with ultrasound or electrohydraulic lithotripsy. Eight patients were stone-free and two had small residual stones 3 months later; nine were stone-free 6 months after the procedure. Although more invasive than shock-wave lithotripsy, percutaneous endoscopic cholecystolithotripsy has the advantage of immediate removal of more calculi, causes less pain, necessitates less postoperative immobilization, and allows patients to leave the hospital sooner.

Stonebearing gallbladders: CT anatomy as the key to safe percutaneous lithotripsy. Work in progress.

Percutaneous cholecystolithotripsy can be performed with a transhepatic or transperitoneal approach. Because the anatomy of the gallbladder varies from person to person, the authors began a study to evaluate the position of the gallbladder with computed tomographic scans of 100 patients known to have stones in their gallbladders. Four variations in the relationship of the gallbladder to the liver and anterior abdominal wall were noted: completely intrahepatic gallbladders (39%) (type I), gallbladders bulging anterior to the anterior rim at least in part (35%) (type II), gallbladders completely anterior to the liver (17%) (type III), and gallbladders in a lateral position (9%) (type IV). In 51%, the colon was in direct contact with the gallbladder, and in 13% it was positioned between the abdominal wall and gallbladder. A safe percutaneous puncture was not possible in 34% of the patients (nine type IV gallbladders, 23 type I organs, and two type III gallbladders with anterior interposition of the colon).

Local and systemic effects of chronic intracavernous injection of papaverine, prostaglandin E1, and saline in primates.

To compare the local and systemic effects of chronic intracavernous injection of papaverine, prostaglandin E1, and saline on erectile tissue, eight pigtail monkeys underwent 75 injections over a nine-month period. Monkeys were divided into three groups; each group received papaverine (10 mg.), prostaglandin E1 (20 micrograms.), or saline (one ml.). The erectile response was closely observed for two hours after each injection to monitor the onset, degree, and duration of erection. Liver function tests were performed every three months to detect early systemic metabolic changes. After sacrifice, the simian penises were perfused in situ and examined histologically with both light and electron microscopy. Papaverine resulted in an initially strong erectile response, but this was maintained throughout the length of the study in only two monkeys. In contrast, prostaglandin E1 resulted in tumescence that was maintained in all monkeys over the nine-month period. In addition, the papaverine group had elevated liver enzymes and significant histologic changes with loss of normal architecture on both light and electron microscopy. The other two groups showed only minimal histologic changes or none.

Extracorporeal shock wave lithotripsy performed on woman with a cardiac pacemaker.

A 73-year-old woman with a sick sinus syndrome and a 3-year-old ventricular demand pacemaker underwent extracorporeal shock wave lithotripsy without incident. There was no damage or malfunction of the pacemaker during or acutely after this therapy. The lithotriptor had no difficulty in sensing all paced or spontaneous ventricular complexes.

Intracavernous injection of prostaglandin E1 in impotent men.

Intracavernous injection of prostaglandin E1 was used in 210 men as a screening test for the differential diagnosis of vasculogenic impotence. Of these 210 patients 112 entered an autoinjection protocol for treatment of erectile dysfunction. Prostaglandin E1 appears to be effective in the diagnosis and treatment of nonvasculogenic impotence because it is a physiological agent that is metabolized locally within the cavernous tissue. Additionally, in our series neither systemic reactions nor priapism occurred, nor was fibrosis of cavernous tissue or scar formation observed after up to 90 injections.