[Treatment mapping of prostate cancer in DVPZ prostate centers in Germany]. / Versorgungsabbild zum Prostatakarzinom in DVPZ-Prostatazentren in Deutschland.

BACKGROUND: In prostate centers of the Governing Body of German Prostate Centers (DVPZ, Dachverband der Prostatazentren Deutschlands e.V.) treatment data from 3 university clinics, 21 treatment clinics, 3 private clinics and 330 general practitioners incorporated under 22 certificates are collated, in order to document the quality and type of cross-sectoral and interdisciplinary treatment, in particular of prostate cancer (PCA) patients. METHODS: This analysis is based on the DVPZ UroCloud data sets from 20 July 2015. The UroCloud reflects the web-based chronological disease development and quality parameters. For the descriptive analysis of particular key figures, available complete data sets were selected. RESULTS: Of the centers 22 held a valid certificate and fulfilled all required case numbers and structural prerequisites at the primary certification or recertification. In three cases a reauditing led to requirements before certification. Since 2005 a total of 9650 PCA patients have been pseudonymized and followed up (41,247 follow-up forms, 4.3 forms per patient). In 2014 the median number of newly documented PCA patients was 61 per center (minimum 7 and maximum 295). Radical prostatectomy (RP) dominated with 4491 (56 %) cases followed by primary hormonal therapy (1210 cases, 15 %), irradiation (809, 10 %) and non-interventional therapy, such as active surveillance (AS) or watchful waiting (WW) in 760 cases (10 %). A prostate-specific antigen (PSA) reduction was documented in 50 % of the patients with a preoperative PSA value > 20, in 60 % of pT4 tumors and in 50 % of patients with a tumor Gleason score of 9-10. A positive incision margin (R+) was found in in 15 % of pT2 stages, 41 % of pT3 stages and 85 % of pT4 stages. A secondary intervention was documented in 6.5 % of RP. CONCLUSION: The DVPZ certificate reflects the complete spectrum of treatment of PCA patients. The strength of the certificate lies in the documentation of patient development and a simultaneous collation of quality parameters.

[Fistula between the bladder and vagina after implantation of a ureteric thermo-stent for radiogenic long segment stricture of the left lower ureter]. / Harnblasenscheidenfistel nach Implantation eines Harnleiterthermostents bei radiogener langstreckiger prävesikaler Harnleiterstenose.

The implantation of ureteric thermo-stents in the treatment of benign and malignant ureteric strictures is, besides ureterocystoneostomy, replacement of the ureter by intestine, double-J catheter, and nephrostomy, an alternative therapeutic option. We report on a female patient with a radiological long segment stricture of the left lower ureter who developed a fistula between the bladder and vagina 6 months after implantation of a ureter thermo-stent because the distal end of the thermo-stent extended into the bladder.

[Renal trauma: is open surgery still up to date?]. / Das Nierentrauma: Ist eine offen operative Therapie noch aktuell?

For several years conservative treatment of renal trauma has been increasing. Investigation of circulatory conditions, renal ultrasound, and CT scan are necessary for assessing the extent of renal injury by the exact classifications of the organ injury scale. Through close cooperation of all departments involved, especially intensive care, traumatology, general surgery, radiology, and urology, it should be possible to limit primarily operative open surgery to life-threatening renal bleeding (grade V). All other cases require a repeat diagnosis for control purposes after 2-4 days. Complications found then can for the most part be treated conservatively or by minimally invasive techniques. Thus, open operative intervention has been minimized in these cases too.

[Traumatic paraplegia. Possibilities of therapy and rehabilitation in a modern treatment center]. / Die traumatische Querschnittlähmung. Möglichkeiten von Therapie und Rehabilitation an einem modernen Behandlungszentrum.

After foundation of treatment centres for paraplegics using the concept of comprehensive care by Sir Ludwig Guttmann in 1943, the treatment goal includes the activation of the patient and the integration into society. This is achieved by the immediate admission for surgical treatment of the injured person into a specialized treatment centre which can guarantee all procedures of re-integration. This has to contain a comprehensive medical care including neurourological and physical therapy by using equipment and staff comparable to a hospital of maximum care. Simultaneously, all social and job related steps for integration have to be initiated. The concentration of all therapeutic options in one treatment centre moves the patient into the focus of interest and facilitates a cost-effective and quality oriented work for individual therapy concepts.

Urodynamically controlled management of spinal cord injury in children.

Spinal cord injuries in children are relatively uncommon. However, infants with cervical spine injury have an especially high risk of renal damage. Six patients, 4 of them tetraplegic, aged 15 months to 8 years, were primarily treated by oral anticholinergic medication and intermittent catheterization. With this concept, satisfactory results were achieved in 4 of 6 children for a mean follow-up of 17.7 months. Mean bladder capacity increased by 128% and intravesical pressure was reduced by 35%. While all patients initially presented with a detrusor leak point pressure above 40 cm H2O, in 4 patients detrusor leak point pressure could be sufficiently reduced by initial treatment. One patient required intravesical instillation of oxybutynin; in another patient sphincterotomy was performed. No patient had signs of renal damage. In summary, even in tetraplegic infants, oral anticholinergic medication and intermittent catheterization is a safe and well-tolerated treatment.

Comparison of Bay K 8644, nitrendipine and atropine on spontaneous and pelvic-nerve-induced bladder contractions on rat bladder in vivo.

The effects of the dihydropyridine-type calcium antagonist (nitrendipine) and agonist (Bay K 8644) in comparison to atropine have been studied after intravenous administration on spontaneous and pelvic-nerve-induced contraction of rat urinary bladder. Bay K 8644 increased the basal internal bladder pressure as well as the amplitude of the spontaneous bladder contractions in a dose-dependent manner. In addition, an increase in systemic arterial blood pressure was noted for a period of about 20 min. In the presence of atropine the effects of Bay K 8644 on the urinary bladder were almost completely antagonized. Both nitrendipine and atropine reduced in a dose-dependent manner the amplitude of spontaneous and nerve-induced bladder contraction. The spontaneous and nerve-induced bladder contractions were significantly reduced by atropine or nitrendipine. Only nitrendipine caused a reduction of the spontaneous bladder contraction frequency. The systemic blood pressure was decreased significantly by nitrendipine but not after atropine administration. We suggest that both calcium antagonist and agonist can change the tension of the urinary bladder in vivo. As a side-effect the systemic blood pressure is altered. Atropine can antagonize the effect of BayK 8644 on the urinary bladder and reduces spontaneous and nerve-induced bladder contractions more specifically than nitrendipine.

Influence of papaverine on rat bladder contractions in vivo.

In an acute rat model (in vivo) spontaneous rhythmic bladder contractions were induced by ligation of the urethra. In addition single bladder contractions were recorded during neurostimulation of the pelvic nerve. Spontaneous and electrically induced bladder contractions were sensitive to papaverine and isoprenaline in vivo. The basal bladder pressure and bladder contraction parameters were reduced more potently by isoprenaline. Blood pressure decreased significantly after isoprenaline injection (0.5-50 micrograms/kg = 4.73 x 10(-6)-4.73 x 10(-4) mol/l) and high concentration of papaverine (5 mg/kg = 2.95 x 10(-2) mol/l). Compared to isoprenaline papaverine was less toxic. These results are different to previous in vitro investigations in rat bladder strips. In vivo papaverine seems to be less effective on nerve-mediated bladder contractions and decreases bladder pressure. Our results indicate that beta-adrenergic receptors play a potent role in the inhibition of spontaneous and pelvic nerve-induced bladder contraction.

[Primary urethral cancer in the female: a diagnostic and therapeutic challenge]. / Das primäre Urethrakarzinom der Frau: eine diagnostische und therapeutische Herausforderung.

Primary carcinoma of the urethra in women is extremely rare and associated with non-specific symptoms of the lower urinary tract, the vagina and the pelvic floor. On the basis of four case reports, the frequent delay in diagnosis is presented and the therapeutic course is outlined.

Sympathetic inhibition of papaverine induced erection.

We studied the effect of neurostimulation of the lumbar sympathetic trunks on papaverine-induced penile erection in dogs and monkeys. The mean of 124 cm. H2O intracavernous pressure after papaverine injection was reduced under sympathetic trunk stimulation to 40.6 cm. H2O within a mean of 39 sec. In addition the flow of the internal pudendal artery was reduced indicating a decrease of the inflow to the penis. After the sympathetic stimulation was terminated, the intracavernous pressure increased again to the same level as before. This pressure recovery time was delayed after several sympathetic stimulations from 134 sec. (5 min. after papaverine injection) to at least 362 sec. (45 minutes after papaverine injection). Stimulation of the inferior hypogastric plexus had no effect on the intracavernous pressure. The neurostimulation range (3-4V; 20 Hz) was most effective in reducing the papaverine action on penile smooth muscles. The effect of sympathetic trunk stimulation seems to antagonize the relaxing action of papaverine on the cavernous smooth muscles and the cavernous arterioles. Our results imply that high sympathetic tone in some patients with psychogenic impotence may explain their poor response to intracavernous injection of papaverine.

Ultrastructural changes in impotent penile tissue: a comparison of 65 patients.

To determine whether impotence is caused by specific and consistent changes in erectile tissue, we compared the ultrastructure of the corpora cavernosa in 6 controls with that in 59 patients undergoing implantation of a penile prosthesis. The impotent patients were divided into groups based on a medical history of hypertension (10), pelvic surgery (9), alcoholic smokers (8), hypertensive alcoholics (3), hypertensive alcoholic smokers (3), smokers (3), diabetics (8), diabetic smokers (3), Peyronie's disease (3), spinal cord injury (3) and isolated causes (6). Our data demonstrate that different behavioral and/or medical conditions produce similar degenerative tissue responses. There is no single or specific cause of impotence that is manifest by consistent changes in erectile tissue.

Reduction of sympathetic influences on penile erection by phentolamine.

The lumbosacral sympathetic trunks seem to play a major role in penile detumescence. In animal experiments an erection induced by cavernous nerve stimulation can be abolished by neurostimulation of the canine sympathetic trunks. This canine experiment was designed to study the possible reduction of the sympathetic effect by intravenous injection of phentolamine. The aborted erection by sympathetic trunks stimulation was partially antagonized by phentolamine. The arterial flow to the penis as well as the intracavernous pressure were elevated by this drug. As an expected side effect the systemic arterial blood pressure decreased by 4-14 cm H2O after phentolamine injection.

The sympathetic role as an antagonist of erection.

The effects of the lumbar and pelvic sympathetic system on penile erection were studied in a canine model. Erection was induced by cavernous nerve stimulation and detumescence by sympathetic trunk stimulation. Erection induced by cavernous nerve stimulation normally subsides slowly. After discontinuation of electrical stimulation the intracavernous pressure drops within a mean of 291 s to 50% and after a mean of 372 s to 10% of the highest level. However, stimulation of the sympathetic trunk at the level of L4-S1 applied directly after discontinuation of cavernous nerve stimulation accelerated this drop of intracavernous pressure significantly: to 50% after a mean of 19 s and to 10% after a mean of 36 s. If stimulation of the sympathetic trunk was initiated 20 s before cavernous nerve stimulation, the pressure rise was aborted completely. Neurostimulation of the hypogastric nerves alone or in combination with cavernous nerve stimulation did not change the intracavernous pressure. These results were not altered after neurotomy of the pudendal or hypogastric nerves. The main pathway of the fibers from the sympathetic trunk to the penis seems to run via the pelvic plexus. The stimulation voltage and frequency to induce erection or detumescence were equivalent. Our results suggest that an elevated central sympathetic tone may be one of the causes of psychogenic impotence.

Effects of papaverine on tension and 45Ca-uptake in isolated urinary bladder.

Papaverine is believed to relax smooth muscle by reducing transmembrane calcium transport and cyclic nucleotide phosphodiesterase activity. The present study characterizes the different relaxing effects of papaverine on isolated muscle strips of rat bladder dome. Compared to histamine, norepinephrine and serotonin, carbachol and high potassium induced the most prominent contractions in rat bladder strips. For this reason both agents were used as stimulants. High-potassium-induced muscle contractions were reduced by a lower concentration of papaverine than carbachol-induced muscle concentrations. Compared to verapamil, papaverine, especially in low concentrations, was less potent on both kinds of induced muscle contractions. These tension responses correspond to a difference in 45Ca uptake, suggesting a nonspecific blocking property of papaverine on transmembrane calcium channels. The beta-sympathomimetic effects of isoprenaline on carbachol-induced contractions were not enhanced by verapamil. In contrast, papaverine increased this tension response of isoprenaline on carbachol-induced contraction. From these results it is possible that part of the papaverine action seems to be related to an intracellular mechanism probably to cAMP.

Norepinephrine involvement in penile detumescence.

Adrenergic neurotransmission was studied in dogs. Blood samples for catecholamine assay were collected from the flaccid penis, the erect penis after cavernous nerve stimulation and during detumescence induced by sympathetic trunk stimulation. Epinephrine concentration was not significantly different in these three stages. However, norepinephrine concentration increased significantly (p less than 0.005) during induced detumescence from 505 +/- 311 [pg./ml.] to 747 +/- 489 [pg./ml.]. Intracavernous application of norepinephrine abolished cavernous nerve induced erection in a dose dependent manner. Sympathetic trunk stimulation reduced or abolished erection induced by acetylcholine or by vasoactive intestinal polypeptide. We conclude that norepinephrine is an important neurotransmitter in the control of penile detumescence.

Correlation of altered penile ultrastructure with clinical arterial evaluation.

We investigated the ultrastructural changes in the penile erectile tissue from 32 consecutive patients who underwent penile prosthesis implantation. Because most of the patients had undergone papaverine injection with or without duplex ultrasonography, we compared these results with the electron microscopic findings. In patients with a good arterial response and full erection after papaverine injection the ultrastructural findings were similar to those reported in normal men. In patients with moderate arterial disease a distinct increase in mitochondria with aggregation and cytoplasmic vacuolization in smooth muscle cells was noted. These findings could be interpreted as an active cellular attempt to respond to the altered environmental and nutritive situation. In patients with severe arterial insufficiency the cellular structure was markedly altered, the number of intracavernous smooth muscle cells was reduced and the density of the connective tissue separating individual cells was increased. These changes in the smooth muscle cells consisted of contour irregularity with fragmentation and loss of the basal lamina. The cytoplasm was largely devoid of contractile elements. The nuclei tended to be pleomorphic with unevenly distributed chromatin. The endothelium was also altered significantly in this group. A careful clinical evaluation of penile arterial function should be performed in all patients undergoing penile arterial or venous corrective surgery. If doubt remains, a penile biopsy may be indicated.

[Percutaneous treatment of a renal pelvis-calyx cholesteatoma]. / Perkutane Therapie eines Nierenbeckenkelch-Cholesteatoms.

A 54-year-old women reported recurrent pain in one side. Radiological and ultrasonographic examination revealed a mass in the left renal pelvis and the lower calyx. With percutaneous calycopyeloscopy keratinous fragments of a cholesteatoma were found and extracted during the same procedure. Up to now, malignant degeneration of a cholesteatoma has never been reported in the literature. Therefore, a conservative surgical treatment is acceptable.

The effect of subatmospheric pressure on the simian penis.

The effects of subatmospheric pressure on the simian penis were studied in nine monkeys under anesthesia. A plastic cylinder was placed over the penis and suction applied until the gauge pressure was -100 to -200 cm. H2O. The intracavernous pressure decreased within one to three seconds to between -60 and -120 cm. H2O followed by a gradual increase as a result of blood flow into the corpora cavernosa. The intracavernous pressure recovery was 50% after 17 seconds and 100% by 30 to 60 seconds. These effects could also be observed when the penile base was partially constricted with a rubber band before applying the partial vacuum. Tumescence resulting from suction disappeared immediately when suction was terminated unless the base of the penis was constricted before and after the application of vacuum. In the latter case tumescence was prolonged (cavernous pressure between 60 and 120 cm. H2O) after suction. The cross-sectional area of the penis expanded to more than 150% of the flaccid state. The increase of intracavernous pressure from intracavernous papaverine injection was similar to that after suction with a constricting rubber band in place at the base of the penis. Subatmospheric pressure induces an expansion of the penis followed by increased blood inflow. The additional volume can be kept in the penis only if a constriction device is placed at the base of the penis. The tumescence induced by suction is passive, occurring without evidence of smooth muscle relaxation or release of neurotransmitters.

[Diagnosis of a venous fistula as a cause of erection disorders. Experimental principles and practical conclusions]. / Die Diagnose des venösen Lecks als Ursache von Erektionsstörungen. Experimentelle Grundlagen und praktische Schlussfolgerungen.

An experimental study was done in ten dogs and eight monkeys to evaluate the accuracy of dynamic and pharmacologic cavernosometry and cavernosography in the diagnosis of venogenic impotence. Our findings show that erection induced by saline perfusion comes about because the penile venous outflow capacity is exceeded. Thus, the cavernous occlusive mechanisms are not activated. Cavernosography in induced erection always demonstrated the entire cavernous venous system. However, cavernosometry after pharmacologic cavernous smooth muscle relaxation provides useful diagnostic information. Similarly, cavernosography after pharmacologic cavernous smooth muscle relaxation proved to be useful for the identification of abnormally draining veins.

Possible role for acetylcholine as a neurotransmitter in canine penile erection.

In 15 adult dogs, the possible role of acetylcholine as a parasympathetic neurotransmitter in canine penile erection was investigated. Intracavernous injection of increasing dosages of acetylcholine (0.1-100 micrograms) induced a dose-dependent erectile response with increased arterial flow, cavernous smooth muscle relaxation, and venous occlusion. This erectile response was completely abolished after muscarinic blockade by intracavernous injection of 0.1 mg atropine. After cavernous nerve stimulation, atropine injection significantly reduced the pudendal arterial flow (by 25%) and likewise caused a significant reduction in cavernous outflow restriction. Histologic staining showed acetylcholinesterase-positive fibers around the cavernous arteries and within the cavernous erectile tissue.