Outcomes of a prospective multi-center trial of a second-generation composite mesh for open ventral hernia repair.

PURPOSE: Composite mesh prostheses incorporate properties of multiple materials for use in open ventral hernia repair (OVHR). This study examines clinical outcomes in patients who underwent OVHR with a polypropylene/expanded polytetrafluoroethylene (ePTFE) composite graft containing a novel polydioxanone (PDO) absorbable ring to facilitate placement and graft positioning. METHODS: Data were prospectively collected on consecutive patients undergoing OVHR using a synthetic composite mesh. Seven centers enrolled patients during the study period. All patients underwent a standardized surgical procedure consisting of OVHR with sublay intraperitoneal placement of mesh. Mesh fixation was accomplished with peripheral tacks and transfascial sutures. RESULTS: One hundred and nineteen patients underwent OVHR with the composite mesh. Average age was 55.8 years; there were 71 (59.7 %) females and 48 (40.3 %) males with mean BMI of 33.5 ± 7.1 kg/m(2). One hundred and two (85.7 %) patients presented with primary ventral hernias. Mean defect size was 13.6 cm(2), and mean mesh size was 113.6 cm(2). Most patients (67 %) were discharged the day of surgery. Twelve patients (10.1 %) experienced complications in the perioperative time period primarily consisting of seroma (4.2 %) and ileus (1.7 %). Two patients required reoperation and mesh removal in the early postoperative period for infection and herniorrhaphy site pain, respectively. There was a decline in pain and movement limitation scores between baseline and 1-year follow-up. Six-month (n = 109) and twelve-month (n = 99) follow-up revealed no hernia recurrences (95 % CI 0-3 %, and 0-4 %, respectively). CONCLUSIONS: The use of this second-generation composite mesh was associated with no hernia recurrences and a low complication rate after open ventral hernia repair.

[Gemcitabine/cisplatin vs. MVAC. 5 year survival outcome of the phase III study of chemotherapy of advanced urothelial carcinoma in Germany]. / Gemcitabin/Cisplatin vs. MVAC. 5-Jahres-Ergebnisse der Phase-III-Studie zur Chemotherapie des fortgeschrittenen Urothelkarzinoms in Deutschland.

Of 405 patients with stage IV transitional cell carcinoma from an international multicenter phase III trial, 70 were randomized in Germany to receive either gemcitabine/cisplatin or standard MVAC systemic chemotherapy for locally advanced or metastatic urothelial cancer. Overall survival as the primary endpoint of the study was similar in both arms (median survival GC 15.4 months vs MVAC 16.1 months), as were tumor-specific survival and time to progressive disease. In the intent-to-treat analysis, the 5-year overall survival rate was 10% for patients randomized to GC and 18% randomized to MVAC. Tumor overall response rates (GC 54%, MVAC 53%) were similar. The toxic death rate was 0% in the GC arm and 3% (one patient) in the MVAC arm. Significantly more GC than MVAC patients experienced grade 3/4 anemia (GC 52%, MVAC 20%) with significantly more red blood cell transfusions in the GC arm.Significantly more GC than MVAC patients had grade 3/4 thrombocytopenia (GC 54%, MVAC 17%) without grade 3/4 hemorrhage or hematuria in either arm. More MVAC patients experienced grade 3/4 neutropenia (GC 56%, MVAC 61%, p=1.000), neutropenic or leukopenic fever (GC 0%, MVAC 10%, p=0.237), mucositis (GC 0%, MVAC 7%, p=0.495), and alopecia (GC 6%, MVAC 36%, p=0.004). GC represents a reasonable alternative for the palliative treatment of patients with locally advanced and metastatic transitional cell carcinoma. Sustained long-term survival was only found for patients with locally advanced cancer, lymphatic metastases, or solitary distant metastasis but not for visceral metastatic disease.

[Therapy of benign prostatic hyperplasia with alpha receptor blockers]. / Therapie der BPH mit alpha-Rezeptorenblockern.

The therapeutic efficacy of alpha-blockers in disorders of bladder emptying has been known for 20 years. Substantial side effects initially prevented their wide use in benign prostatic hyperplasia. The situation has changed with the development of the very much better tolerated selective alpha 1-adrenoceptor antagonists. In numerous countries, alpha 1-blockers are also licensed for use in the treatment of benign prostatic hyperplasia in addition to the main indication, vascular hypertension. Of those available in Germany, the slow-acting antihypertensive agents terazosin and doxazosin are the most suitable for use in this condition. The modern alpha 1-blockers have proved their effectiveness in large-scale placebo-controlled studies. However, the effects consist solely in improvement of the subjective symptoms and a moderate increase of urinary flow and are not comparable to those achieved with transurethral resection. alpha 1-Blockers are indicated in patients with moderate to fairly severe symptomatic benign prostatic hyperplasia (as an alternative, for example, to phytotherapeutic agents) and in patients who have severe symptoms but for whom surgical treatment is not desired, needs to be postponed or is contraindicated. Side effects arise from the concomitant vasodilatation, so that contraindications for alpha-blockers are cardiac and renal failure, a prior history of cerebrovascular incidents and a tendency to hypotension. Further attenuation of these side effects appears possible with the future development of "uroselective" alpha 1-blockers.

Treatment of advanced renal cell cancer with recombinant interferon alpha as a single agent and in combination with medroxyprogesterone acetate. A randomized multicenter trial.

The response rates in metastatic renal cell cancer (RCC) after chemotherapy, hormonal treatment, or immunotherapy rarely exceed 15%. Recently, interferon alpha (IFN alpha) was used for treatment of this disease in several studies which also demonstrated response rates of 15%. In order to test whether IFN therapy combined with hormones would result in higher response rates we compared single agent IFN therapy with a combined therapy of rIFN alpha 2C plus medroxyprogesterone acetate (MPA) in a randomized multicenter trial. The rIFN alpha 2C (2MU) was given s.c. 5 times per week for 8-12 weeks and subsequently once weekly until week 48. In the combined treatment, 750 mg MPA was given p.o. daily until week 48 in addition to the IFN as described. The overall response rate in 93 evaluable patients was 5.4% corresponding to 2 complete and 3 partial responses. Median survival was 7 months in both treatment groups. These data confirm the ineffectivity of low IFN doses for treatment of RCC. The low response rate is not increased by addition of MPA to IFN. The analysis of other IFN studies suggests that not only IFN doses but also IFN sources may influence response rates in metastatic RCC.

[Pyelonephritis in patients with congenital malformations of the urinary tract after corrective operation and under antibiotic therapy (author's transl)]. / "Urologisch bedingte" Pyelonephritis: Verlauf unter medikamentöser Therapie nach operativer Behandlung der kongenitalen Harnwegsfehlbildung. Langzeitbeobachtungen an 398 kinderurologischen Fällen aus fünf Jahrgängen

398 (otherwise unselected) children with certain types of congenital urinary tract malformation were followed up for a period of not less than three years for evaluation of the infection rate after surgical correction (the latter performed in 1968 to 1972). During a six month course post op., all patients received appropriate antibacterial drugs, thereafter cessation of medical treatment depending upon normal findings in urinalysis. The over-all cure rate was 77% after six months, 85% after twelve months, 95% after two years and 97% after three years. No recurrence of urinary tract infection was observed three years after surgery of in frapelvic ureteral stenosis/hydronephrosis (n=86; Anderson-Hynes procedure) in 100%; of distal ureteral stenosis/megaureter (n=76; Politano-Leadbetter or occasionally Boari approach) in 92%; and of primary reflux (n=236; Lich-Grégoir technique) in 98%. The incidence of infectious relapse following any normal cytological and bacteriological control was 1% resp. 7% resp. 2%, with an average of 3% for all three groups.

Estrogenic sensitivity of alpha-receptors in the urethra musculature.

Estrogene has a tonicising effect upon urethra musculature. There is also the same demonstrable influence of alpha-receptor stimulating drugs upon the urethra pressure profile. After preliminary treatment with estrogene, there is a considerably stronger tonicising effect of alpha-stimulating drugs than without such a treatment. So the combination of estrogene and alpha-stimulating drugs seems a useful addition to the conservative treatment of stress incontinence.

PIP: Estrogenic sensitivity of alpha-receptors in the urethra musculature was investigated. The main object of this study was to determine if est rogene could cause the alpha-receptors to be more sensitive to the alpha -receptor stimulating drugs, so that by using an equal dosage of alpha-r eceptor stimulating drugs in a preliminary estrogenic treatment, a stronger tonic effect would be achieved in the urethra musculature than by using the alpha-receptor stimulating drugs alone. 5 healthy continen t females and 3 females suffering from 1st-degree stress incontinence were studied. There was a demonstrable influence of estrogene upon the urethra musculature. And there was also the same demonstrable influence of alpha-receptor stimulating drugs upon the urethra pressure profile. Following preliminary treatment with estrogene, there was a considerally stronger tonicising effect of alpha-stimulating drugs than without such a treatment. Therefore, it appears that the combination of estrogene and alpha-stimulating drugs is a useful addition to the conservative treatment of stress incontinuence.

Conservative bladder treatment in myelodysplasia. Differentiation of patients by cystomanometry.

Urodynamic evaluation was performed in 75 patients with congenital neuropathic bladder. Concerning treatment the most important parameters were detrusor tone, detrusor activity and bladder outlet resistance. Based on these findings individual conservative therapy was applied. Reflux or dilatation of the upper urinary tract found in 26 children could be controlled by drugs or transurethral operations in 20, urinary diversion had to be done only 4 times. 26 children were selected for intensive treatment of incontinence; in about 50% satisfying urinary control was achieved. These results still need long-term observation. The main interest, however, was to postpone irreversible surgery and to gain time for possible better treatment in the future.

[Experimental studies in animals on the bladder function following sacral blockade with alkohol (author's transl)]. / Tierexperimentelle Untersuchungen der Blasenfunktion nach Alkolol-Sakralblockade

Caudal anesthesia was achieved with Xylocain-R in 13 dogs and with ethanol (99,2 percent) in 8 dogs. Urinary bladder function was studied before and after block. The results obtained are in agreement with the functional changes after rhizotomy of S1--S3: bladder capacity increases after cuadal block and pressures measured at equal volumes decrease. Urinary overflow was observed; 80 percent of the filling volume, however, remains within the bladder. An autonomous bladder contraction induced by smypathetic nerve activity could not be proven within our observation period of 7 days.

Treatment with phenoxybenzamine of upper urinary tract complications caused by intravesical obstruction.

Five children in whom reflux and progressive hydronephrosis persisted despite multiple surgical attempts or repair are described. In all cases cystomanometry displayed a marked elevation of the bladder outlet resistance combined with high intravesical pressure values. Therapy with phenoxybenzamine, an alpha-adrenergic blocker, was successful in all cases, restoring a free urine passage of the upper urinary tract and unimpaired voiding preventing urinary diversion which has been considered in some of these children. Although there were no signs of bladder neuropathy, a hyperfunction of the sympathetic innervation as acause for bladder complications is discussed.