[Magnetic urethral closure device. Negative outcome after implantation for the treatment of female urinary incontinence]. / Magnetisches Harnröhrenverschlusssystem. Desaströser Verlauf nach Implantation zur Behandlung der weiblichen Belastungsinkontinenz.

We report on a negative outcome after implantation of a magnetic urethral closure device, consisting of one part screwed into the pubic bone and one part as a vaginal cone, for the treatment of urinary stress incontinence grade III. Continence was never achieved for the patient. The urethra narrowed over time due to erosion and scarring and the patient started intermittent catheterization, because spontaneous micturition was not possible. The magnet was broken, the bladder neck was eroded, several fragments were found in the bladder, and numerous fragments were scattered throughout the small pelvis. Surgery consisted of removing most of the fragments, followed by bladder neck closure and suprapubic diversion.

[The retropubic ganglion as a rare tumour entity in the lesser pelvis: case report and literature survey]. / Das retrosymphysäre Ganglion als ungewöhnliches Tumorgeschehen im kleinen Becken: Ein Fallbericht und Literaturübersicht.

Retropubic tumours without contact to bones or surrounding tissues are extremely rare with only 22 cases being reported in the literature. The majority of tumours described within these reports are osteochondromas in 17 cases, 2 cases of leiomyoma and one case of each fibroma, fibrosarcoma and nodular fasciitis. We now report the case of a 52-year-old-man with a retropubic ganglion cyst, which was resected "in toto" by laparoscopy.

[Rehabilitation of erectile function after nerve-sparing radical prostatectomy: therapeutic concepts in Germany]. / Rehabilitation der erektilen Funktion nach nervenschonender radikaler Prostatektomie : Therapiekonzepte in Deutschland.

OBJECTIVE: Despite objective published data regarding rehabilitation of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) the gold-standard treatment is still under debate. The aim of this study was to evaluate the distribution of the different treatment options in Germany. PATIENTS AND METHODS: Between October 2010 and May 2012 a questionnaire was sent to urologists in outpatient, general and university hospitals and rehabilitation hospitals in Germany. The survey consisted of various questions concerning, e.g. if and what kind of therapy urologists choose to support rehabilitation of EF after nsRP. Further questions dealt with the frequency, duration and optimal start of the chosen therapy. RESULTS: Currently 188 urologists have completed and returned the questionnaire. The distribution was urologists in hospitals n=79 and outpatient/ambulatory n=106, with 24 % performing surgical treatment and urologists in rehabilitation hospitals n=3. The question about the rehabilitation concept showed 39 different forms of treatment within this group. To increase EF after nsRP PDE5 inhibitors were mostly administered (88 %) with 45 % on request compared to 55 %on a daily or regular basis ≥ 3 times/week. The use of penile injection therapy, medicated urethral system for erection (MUSE) and vacuum constriction devices (VCD) was prescribed by 32 %, 6 % and 30 % of urologists, respectively. Only 14 % of the urologists did not choose any active kind of rehabilitation treatment for EF recovery after nsRP. CONCLUSION: Many different therapeutic concepts are currently performed in Germany to increase EF recovery after nsRP. The use of PDE5 inhibitors is the most commonly chosen treatment option. Despite published data regarding effectiveness, the optimal treatment seems to be still unknown.

The real-life safety and efficacy of vardenafil: an international post-marketing surveillance study--results from 29 358 German patients.

We assessed the safety, efficacy and patient acceptability of vardenafil (Levitra, Bayer HealthCare, Leverkusen, Germany) under real-life conditions in patients with erectile dysfunction (ED) in a multinational post-marketing surveillance study. An initial and up to two follow-up visits were documented for 29 358 German ED patients receiving vardenafil. Patients were interviewed about overall treatment success, and individual sexual attempts were evaluated in a patient questionnaire. Overall erectile improvement was reported by 93.9% of physicians, and similar improvement rates were reported for both 10 mg and 20 mg vardenafil dosages. Most patients experienced improved erections after the first (73.6%) or second (88.5%) tablet. Sexual attempts were successful with respect to partner penetration in 94.9% of patients and with respect to maintenance of erection during intercourse in 87.7% of patients. Adverse drug reactions were very rare (1.3% of patients). Vardenafil was highly effective, reliable and well tolerated in ED patients treated under real-life conditions.

[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.

Simple reinforcement for thin nephrostomy catheters.

PURPOSE: Nephrostomy catheters are prone to kinking or damage because the thin, flexible silicone tube is too vulnerable against mechanical stress even when the proximal end is carefully fixed. We developed a simple method to reinforce the outside part of a thin catheter protruding from the skin. MATERIALS AND METHODS: We treated 7 children with nephrostomy catheters or ureteral stents with a diameter of 8F or smaller. After insertion a large plastic tube was wrapped around the small catheter, and fixed to the skin and to the peripheral collection system with adhesive tape. RESULTS: Handling of the catheters improved and there was less need for re-fixation. CONCLUSIONS: Thin nephrostomy catheters can be effectively protected by wrapping them into a larger, outer tube after insertion.

Does the success of ureterointestinal implantation in orthotopic bladder substitution depend more on surgeon level of experience or choice of technique?

PURPOSE: We attempted to determine the relative risk of ureterointestinal anastomosis using 2 antireflux techniques of orthotopic bladder substitution, and we assessed the degree to which success is determined by surgeon experience. MATERIALS AND METHODS: A total of 120 patients underwent surgery, including 74 with the Hautmann (Le Duc) technique and 46 with a somewhat modified Studer (Nesbit/Studer) technique. The urologists who performed the operations were classified as expert, skilled and learner. Evaluation was done retrospectively. All patients in the Studer group, except 3 who died and 1 who was lost to followup, were monitored a minimum of 12 months. RESULTS: There was a 20.4% rate of nonneoplastic obstructions in the 142 ureters reimplanted with the Le Duc technique (Hautmann group). The variation in obstruction rates of 16.7, 18.2 and 25%, respectively, for expert, skilled and learning surgeons was statistically insignificant. Only 3 nonneoplastic obstructions (3.6%) developed in the 83 ureters reimplanted with the Nesbit/ Studer technique (Studer group). The variation in obstruction rates of 5.1, 0 and 3.6%, respectively, for expert, skilled and learner surgeons was statistically insignificant. CONCLUSIONS: The Nesbit/Studer technique results in a generally lower rate of ureterointestinal anastomotic stricture than the Le Duc technique. Using the Le Duc technique there was no statistically significant correlation between incidence of obstruction and surgeon level of experience, indicating that obstruction with this technique probably arises from other factors.

[Rational diagnosis and surgical therapy of renal cell carcinoma with tumor thrombosis in the vena cava]. / Rationelle Diagnostik und operative Therapie des Nierenzellkarzinoms mit Tumorthrombus in der V. cava.

Venous involvement in renal cell carcinoma (RCC) represents an advanced state of disease. Nonetheless, its influence on survival is rather secondary compared with that of local tumor growth, grading and metastasis. Since conservative treatment in advanced RCC is mainly ineffective, surgical management offers the most promising approach for potential cure. Only patients without metastasis, however, seem to benefit from an aggressive surgical intervention. The surgical technique itself is determined by the vena caval extent of the tumor thrombus. Preferably, noninvasive imaging techniques should provide information about metastasis and the extent of the tumor thrombus. Diagnostic efforts should be adapted to therapeutic feasibility and prognosis in every individual patient in order to avoid fatiguing and costly over-examination. The standards requested above can be realized by use of modern sonographic and computed-tomographic imaging techniques or by magnetic resonance imaging alone. Thus, nowadays, the essential diagnostics in RCC with vena caval involvement may dispense with angiographic examinations.

Modified ureteral stripping as an alternative to open surgical ureterectomy.

PURPOSE: Using a compression technique instead of the classical invagination technique in cases of total nephroureterectomy improves traction during transurethral stripping of the ureteral stump. MATERIALS AND METHODS: Eight patients underwent our modified compression technique. After nephrectomy a kinked 5F ureteral catheter is attached to the ureteral stump with a double ligation. Traction on the ureteral catheter is used to achieve ureteral compression. RESULTS: There were no intraoperative difficulties except for 1 dislodged ureteral catheter. No complications were associated with ureteral detachment or resection. CONCLUSION: Our technique offers an alternative to the classic invagination technique by increasing transurethral traction on the ureteral stump, while substantially decreasing the risk of ureteral catheter dislodgment.

[Superselective embolization of tumor nodes in solitary kidney in inoperable patients]. / Superselektive Embolisation von Tumorknoten in Einzelnieren bei inoperablen Patienten.

PURPOSE: Evaluation of superselective embolisation of renal tumours in inoperable patients with solitary kidneys. METHODS AND PATIENTS: Eight inoperable patients with solitary kidneys bearing tumour nodules underwent 1-3 superselective embolisation procedures with ethibloc (5x) or polyvinyl alcohol (1x). Renal function was monitored with creatinine levels. Tumour size was controlled every three months by means of sonography. RESULTS: Technical success rate was 100%. In 3/3 patients haematuria could be stopped. Post-embolisation renal function was unchanged in 6 patients and deteriorated in two patients; creatinine level rose to a maximum of 2.2 mg%. We observed no other side effects. Seven of eight patients died during a median follow-up period of 9.3 months (4-18 months); in two cases they died due to their underlying malignant disease. One patient had local tumour progress. CONCLUSIONS: Superselective embolisation of renal tumours in patients with solitary kidneys may be a helpful, well-tolerated therapeutic option in inoperable, symptomatic patients.

Surgical management of renal cell cancer with extension into the vena cava: usefulness of intra-operative sonography.

Intracaval tumour extension represents a significant surgical problem in patients with renal cell carcinoma. Although pre-operative imaging techniques provide sufficient visualization for the planning of the majority of operative procedures, intra-operative ultrasound is nonetheless beneficial in some cases. In 3 patients, the procedure has given an accurate evaluation of the extent of the tumour thrombus. It has allowed safe placement of instruments which had lessened the risk of thrombus dislodgement. Intra-operative sonography is simple to perform and can be considered a valuable new adjunct in the evaluation and management of renal cell carcinoma with intracaval tumour extension. New technological advances may eventually improve the quality of intra-operative imaging.

Opiate antagonists in erectile dysfunction: a possible new treatment option? Results of a pilot study with naltrexone.

Opioids have an inhibitory effect on sexual functions in both animals and humans. Twenty patients with idiopathic, nonvascular, nonneurogenic erectile dysfunction were treated with the opiate receptor antagonist naltrexone in a randomized, placebo-controlled, double-blind study for 8 weeks. Libido and frequency of sexual intercourse were not significantly altered, but early-morning erections increased significantly under naltrexone therapy. This response was not related to levels of androgens or gonadotropins, neither was it dose dependent. There was no change in any of the measured parameters under placebo. Further clinical studies with the substance should be conducted to evaluate its possible role in the oral treatment of male impotence.

Evaluation of erectile dysfunction with the sympathetic skin response in comparison to bulbocavernosus reflex and somatosensory evoked potentials of the pudendal nerve.

Sympathetic skin response (SSR) was investigated in 60 normal subjects (mean age 37.7 +/- 15.9) and 30 patients (mean age 47.2 +/- 12.0) referred from the department of urology for further electrophysiological evaluation of erectile dysfunction (ED). SSR was present in all normal subjects. Mean latency in the lower extremities was 2.16 +/- 0.20 sec. The coefficient of variance for repeated measurements in individual subjects was 10%. The latencies correlated slightly positively with the height of the subjects (r = 0.271, p < 0.05), but not with age. SSR in patients was compared to the bulbocavernosus reflex (BCR) and somatosensory evoked potentials (SSEP) of the pudendal nerve. All patients had a complete urological work-up with evaluation of hormonal function, pharmacotesting and Dopplersonography, as well as pharmacocavernosography and measurement of nocturnal penile tumescence if indicated. Six patients were diagnosed to have functional impotence, 4 dysfunctions were probably of vascular origin, 5 were neurogenic and 15 of the mixed type of vascular and neurogenic origin. Diabetes mellitus was the underlying disease in 14. In the two groups with neurogenic involvement (5 neurogen, 15 mixed) 14 of 20 patients had a pathological BCR, 12 had pathological SSEP and 9 had an absent SSR. Of these 9 patients two showed normal BCR and SSEP. Sensitivity for neurogenic dysfunction was 70% for the BCR, 60% for the BCR and SSEP, but that it detects some patients with erectile dysfunction, in whom other parameters are not pathological.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis of urethral diverticulum in women]. / Diagnostik des weiblichen Harnröhrendivertikels.

Urethral diverticula have proved to be a common cause of recurrent urinary tract infections in female subjects. Positive-pressure urethrography, mostly performed by means of double-balloon catheters, has hitherto been regarded as the method of choice for their detection. Unfortunately, the few existing commercial catheter devices have certain disadvantages, which have led to a lack of acceptance of this important technique and restricted its use. We therefore present an improved tool for positive-pressure urethrography and a synopsis of diagnostic visualization procedures for urethral diverticula in women.

Pharmacokinetics of vasoactive substances administered into the human corpus cavernosum.

The pharmacokinetics of vasoactive substances injected into the corpus cavernosum for the treatment of erectile dysfunction have not been investigated to date. We measured the local intracavernous and peripheral venous concentration curves of papaverine and prostaglandin E1, and its primary metabolite 15-keto-13,14-dihydro-prostaglandin E1 in an intra-individual comparison after intracavernous injection. Papaverine was measured with high performance liquid chromatography and prostaglandin E1 was measured with a specially adapted radioimmunoassay. The results demonstrate that papaverine is slowly draining into the systemic circulation, showing slightly elevated levels in the peripheral blood 30 and 60 minutes after injection. Prostaglandin E1 shows a much faster decrease in local concentrations with no measurable increase in the periphery, probably due to the short half-time after lung passage. Measurement of the primary metabolite proves a local degradation of prostaglandin E1 in the corpus cavernosum into the biologically inactive 15-keto-13,14-dihydro-prostaglandin E1, which also shows a slight increase in the peripheral circulation due to the longer half-time of approximately 8 minutes. The data provide good explanation for the clinical finding of a markedly decreased incidence of priapism with the use of prostaglandin E1, which can be shown to be locally metabolized, compared to papaverine, which is retained in the corpus cavernosum in cases of nonvenogenic impotence.

The Alcock syndrome: temporary penile insensitivity due to compression of the pudendal nerve within the Alcock canal.

Penile insensitivity is a symptom commonly observed after traumatic or iatrogenic nerve lesions, or in association with neurological or vascular diseases. In contrast, we report 2 cases of intermittent genital hypesthesia that occurred in cyclists after long-term bicycle riding. Anatomical studies show that this condition was probably caused by an irritation of the pudendal nerve during its course through the Alcock canal as reported in the literature. No pathological findings were demonstrated on extensive physical examinations, medical history and all medical imagings (sonography of abdomen, prostate and testes, and magnetic resonance imaging of the pelvis and lumbar spine) as well as radiodiagnostics and Doppler sonography, nor was there evidence of other neurological disturbances. The symptoms in the 2 patients spontaneously resolved after 4 and 7 weeks, respectively, without specific medical therapy.

Treatment of idiopathic erectile dysfunction in men with the opiate antagonist naltrexone--a double-blind study.

Opiate antagonists can indirectly stimulate the secretion of luteinizing hormone (LH) and testosterone, as well as sexual functions in animals and humans. We therefore treated 20 otherwise healthy men with idiopathic erectile dysfunction aged 46.3 +/- 2.7 years (mean +/- SE, range 23.9-63.3) in a double-blind study with an opiate antagonist, naltrexone, or placebo. The erectile dysfunction of these men had persisted for 3.6 +/- 0.5 years despite libido maintenance; standard procedures had excluded any organic causes. Trial duration was 12 weeks overall. After a 4-week forerun, the patients received at first 25 mg naltrexone/day orally or placebo for 4 weeks followed by 4 weeks of a 50-mg dose of naltrexone/day or placebo. Each day the patients filled out a questionnaire detailing libido, degree of erection, frequency of sexual intercourse, and spontaneous morning erections. Serum concentrations of gonadotropins and testosterone were determined radioimmunologically in the initial stage and at the end of each phase. Both patient collectives had similar initial factors. The group treated with naltrexone showed a significant rise in spontaneous early morning erections during the treatment: from 2.8 +/- 0.3 to 4.2 +/- 0.3 a week (P < 0.001). The placebo group showed no significant change in spontaneous erections (2.4 +/- 0.3 and 2.6 +/- 0.3, respectively). The subjective parameters, however, such as libido, degree of erection, and frequency of sexual intercourse showed no significant difference within each group. There was no difference in LH, follicle-stimulating hormone, or testosterone concentrations in both groups. Thus, treatment with naltrexone significantly raises the rate of spontaneous early morning erections when compared to controls.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnostic evaluation of acute scrotum--testicular perfusion scintigraphy]. / Abklärung des akuten Skrotums--Hodenperfusionsszintigraphie.

The method of and the results obtained with testicular scintigraphy in the differential diagnosis of acute scrotal pain are described. Both sensitivity and specificity were found to be high and in excess of 90%. Misinterpretation of findings is rare and is seldom reported except in case reports. Normal findings usually genuinely reflect absence of disease, and only in the case of suboptimal imaging conditions they might correspond to a false-negative finding in the presence of acute torsion. Chronic torsion may be missed on scintigraphy because of intermediate normalization of arterial perfusion at the time of the investigation. Missed torsion presents a characteristic activity pattern. The halo sign is a proven sign of avitality of the testicle. Orchitis and epididymitis are correlated with hyperperfusion and hyperaemia and are reliably diagnosed by scanning. When testicular scintigraphy is needed immediate availability is essential. In a nuclear medicine department with standard equipment, the investigation can be started within 5 min; it takes about 15 min to perform and the findings can be evaluated within another 5 min. Acute testicular torsion that has already been reliably diagnosed by clinical examination is not an indication for testicular perfusion scintigraphy. This diagnostic procedure is, however, valuable if the clinical findings are equivocal and, especially, if a conservative treatment is planned.