Impact of preoperative antiandrogen medication and nerve-sparing surgery on the outcome of radical prostatectomy.

OBJECTIVES: Radical prostatectomy in antiandrogen-medicated patients, as well as nerve-sparing surgery, has increased within recent years. We investigated the impact of antiandrogen medication on loss of blood and of nerve-sparing surgery on continence and potency. METHODS: A total of 401 men who underwent radical prostatectomy between January 1995 and September 1999 at our clinic were asked about antiandrogenic medication prior to radical prostatectomy and about daily life activities, overall satisfaction, voiding ability, and sexual activities. Consumption of erythrocyte concentrates and cryoprecipitated plasma was taken from the records. RESULTS: The average follow-up was 36 months. Seventy-two percent (n = 289) of our patients replied. Sixty-seven men (23%) who replied to our questionnaire had received antiandrogen medication prior to radical prostatectomy. In 53 (18%) of the men, the nerve-sparing technique was used. In antiandrogen-medicated patients, we observed a significantly elevated consumption of erythrocyte concentrates (antiandrogen-medicated 0.93, not antiandrogen-medicated 0.44; P = 0.013) and of cryoprecipitated plasma (antiandrogen-medicated 0.39, not antiandrogen-medicated 0.08; P = 0.010). Patients who underwent the nerve-sparing technique reported better results in daily life activities, general health status, International Prostate Symptom Score (IPSS), and continence. CONCLUSION: Our results point to a higher quality of life in patients who had undergone nerve-sparing surgery.

[Management of multiresistant bacteria in urology]. / Management multiresistenter Erreger in der Urologie.

Contamination and infection with extensive drug resistant (XDR) bacteria are increasing in urology with the exception of methicillin resistant Staphylococcus aureus (MRSA) (stabilization). They often lead to logistic and therapeutical problems. Only 30-50% of XDR cases are of exogenous origin. To slow this trend, screening, hygiene programs, isolation, decontamination, targeted therapy of symptomatic infections, education programs, and success controls should be applied. Furthermore, all regulatory and legal instructions should be followed. Local hygiene networks help to find apt measures for XDR control. It is important to balance hygiene measures against hygiene hysteria. To prepare urological instruments, a local instrument preparation plan that takes into consideration all legal instructions should be followed. The efforts in health system general prophylactic measures should be supported. Only with consistent implementation in all areas of daily life (health care, local environment, animal husbandry, and soil contaminated within the framework of animal husbandry) can a substantial reduction of XDR bacteria be achieved in the long term.

[Hygiene, Screening and Management of Multidrug-Resistant Pathogens (3MRGN, 4 MRGN, MRSA) in Urology]. / Hygiene, Screening und Management multiresistenter Erreger (3MRGN, 4 MRGN, MRSA) in der Urologie.

The increasing development of resistance to antibiotics has fatal consequences for the treatment of infectious diseases. One of the main causes is the inappropriate use, and therefore overuse, of these substances. Today, multidrug-resistant pathogens are a major problem for facilities of the public health system, especially for hospitals. Pathogens of particular interest are methicillin-resistant S. aureus and multidrug-resistant gram-negative bacteria. Adapted hygienic measures, effective screening and functioning management of affected patients are required to reduce the risk of infection for patients and staff as well as the spread of pathogens.

[Nosocomial infections caused by multiresistant pathogens. Clinical management exemplified by multiresistant Staphylococcus aureus]. / Nosokomiale Infektionen durch multiresistente Erreger. Klinisches Management am Beispiel des multiresistenten Staphylococcus aureus (MRSA).

Nosocomial infections are a serious problem for every hospital for medical and economic reasons. During the last few years, multiresistant strains have been coming to the fore. At the end of the 1970s, the first outbreaks of nosocomial infections of oxacillin- and methicillin-resistant Staphylococcus aureus strains (MRSA) were reported. MRSA outbreaks require a high degree of organization of medical and hygiene procedures for therapy and prevention. Taking our own experiences into consideration, the essential measures for controlling such infections are discussed.

[Management of "forgotten" DJ stent]. / Management beim "vergessenen" DJ-Stent.

Double J (DJ)stents are a comfortable method for assuring urine passage with little or no burden for the patient. However, the lack of or minimal impairment of physical activity has the disadvantage that an inserted DJ stent can be "forgotten". In cases of encrustation, stent removal can be impossible or a stent can tear off. To remove encrusted stents all modern, minimally invasive endourological techniques are used. In rare cases, surgical procedures are essential. To avoid these difficulties, patients with DJ stents have to be closely checked to recognize the beginning of encrustation as early as possible. The removal of DJ stents should be carried out as early as possible in patients for whom they are required only short-term.

[Hygenic measures for Creutzfeldt-Jakob disease]. / Hygienemassnahmen bei der Creutzfeldt-Jakob-Krankheit.

The Creutzfeldt-Jakob disease (CJD) belongs to the so-called prion diseases or transmissible spongiform encephalopathies. The iatrogenic transmission of the pathogen by direct contact with infectious tissue, tissue extracts and surgical instruments has been demonstrated. CJD is not an infectious disease in the usual sense. Transmission is not possible by normal social contact nor by nursing measures just as CJD can not be transferred by normal skin contact or contact with blood, serum or other patient' secretions. Therefore, CJD patients do not have to be isolated, because strict conformity to the generally recognized rules of hygiene is completely sufficient. The high resistance of prions to environmental influences requires the combination of different disinfection and sterilization measures before inactivation of the pathogen occurs and it is possible to exclude transmission by medical products.

[Significance of bacterial prostatic colonization for nosocomial urinary tract infections after transurethral prostate resection]. / Die Bedeutung der bakteriellen Prostatabesiedlung für nosokomiale Harnwegsinfektionen nach transurethraler Prostataresektion.

Nosocomial urinary tract infections (UTI) are frequent complications after transurethral prostatectomy. The resection itself, postoperative catheterization and the prostate are possible causes of these infections. In this prospective study we investigated the influence of bacterial prostatic colonization on the incidence of postoperative urinary tract infections and inflammatory complications. In 78 patients we observed in 42 cases (53.8%) a bacterial prostatitis. In 14 patients (17.9%) we found nosocomial UTI's and in 12 patients (15.4%) inflammatory complications. The incidence of postoperative UTI's increase significantly in patients with positive prostate-cultures. On the other hand we only found corresponding prostate- and postoperative urine-cultures in less than 50%. The presented data are not sufficient to conclude the kind of relevance of bacterial prostatic colonization for postoperative UTI's in transurethral prostatectomy. Under consideration of the significant increase of nosocomial UTI's in patients with positive prostate cultures a perioperative antibiotic prophylaxis seems to be required in general.

[Nephrectomy in acute uncomplicated pyelonephritis]. / Nephrektomie bei akuter unkomplizierter Pyelonephritis.

BACKGROUND: Which complications can develop from uncomplicated pyelonephritis that may require nephrectomy? METHODS: From January 1999 to June 2003 we carried out nephrectomy in ten cases due to abscess formation after acute, uncomplicated pyelonephritis. The medical files were evaluated retrospectively. RESULTS: Nine women and one man were involved. The mean age was 36.2 years. Leading symptoms: flank pain, fever and chills. The mean symptom duration before admission was 14.6 days. Urinary tract infections were caused by Escherichia coli (six), E. coli and Enterococcus (once) and Klebsiella pneumoniae (once). Two cultures were sterile. Indications for nephrectomy were urosepsis (7 cases), anuria (once), increasing abscess formation under antibiotic therapy (once), drastic deterioration of general condition (once). CONCLUSIONS: Uncomplicated pyelonephritis is easy to treat under outpatient conditions with adequate oral antibiotic therapy. Close control must be ensured and clear recovery of symptoms should occur within 48 h. In the case of long duration of symptoms (>6-7 days) or lack of improvement of symptoms under calculated therapy in the first 2 days, inpatient therapy should be initiated because of the high risk of infectious complications. According to our experience, the following patient group is especially at risk: female, symptom duration of at least approximately 1 week, pre-treatment and transfer from another departments.

[Urologic complications after implantation of aortofemoral blood vessel prosthesis]. / Urologische Komplikationen nach aortofemoraler Gefässprothesenimplantation.

After implantation of aorto-femoral grafts, primary ureteral lesions and secondary ureteral obstructions are the most important urological complications. Surgical repair carried out as quickly as possible, including reanastomosis without tension and covering with a peritoneal patch or omentum interposition, seems the best means of preventing secondary complications. In the case of secondary obstructions, the interval between implantation of the graft and the diagnosis of obstruction has to be considered. A wait-and-see strategy is justified in the case of early obstruction without symptoms during the 1st year because of the high rate of spontaneous remission. Obstructions that appear more than 1 year after operation or symptomatic obstructions have to be treated immediately (i.e. duodenojejunal stent, percutaneous nephrostomy). If repeated obstructions after removal of stents or nephrostomies are noted, surgical repair seems to be indicated. Stents or nephrostomies as definitive procedures are appropriate only in patients in whom surgical revision is not possible or desirable.

[Molecular biology studies of bladder cancer]. / Molekularbiologische Untersuchungen beim Blasenkarzinom.

The mechanisms that control the biological behaviour of urothelial cancer are complex, and many regulative interactions are involved. So far, few aspects of these control mechanisms have been recognized and characterized. A precondition for better understanding is knowledge the interaction of this factors. Some markers (e.g., chromosomal aberrations, EGFR expression) are correlated with progression of tumour. Whether they are the cause or the result of the aggressive behaviour of growth remains unknown. Only a few markers, especially in flow cytometry, will have any benefit in clinical routine. Whether it is possible to find a marker with prognostic value remains uncertain.

[European Association of Urology guidelines on urinary and male genital tract infections]. / Synoptische Leitlinie der sexuell übertragbaren Erkrankungen (STD) mit Primärsymptomen im männlichen Genitale (S1). Leitinien der Deutschen Gesellschaft für Urologie.

Today, the classical bacteria that cause venereal diseases, e.g. gonorrhea, syphilis, chancroid and inguinal granuloma, only account for a small proportion of all known sexually transmitted diseases (STDs). Other bacteria and viruses as well as yeasts, protozoa and epizoa must also be regarded as causative organisms of STD. Taken together, all sexually transmitted infections comprise more than 30 relevant STD pathogens. However, not all pathogens that can be sexually transmitted manifest diseases in the genitals and not all infections of the genitals are exclusively sexually transmitted. Concise information and tables summarising the diagnostic and therapeutic management of STDs in the field of urology allow a synoptic overview, and are in agreement with the recent international guidelines of other specialist areas. Special considerations (i.e. HIV infection, pregnancy, infants, allergy) and recommended regimens are presented.

[Adjustable transobturatoric sling system in men : diagnosis and therapy recommendations to persistent pain]. / Adjustierbare transobturatorische Schlingensysteme beim Mann : Diagnostik und Therapieempfehlungen bei persistierenden Schmerzen.

BACKGROUND: In addition to artificial sphincters, male slings are recommended in the current guidelines for the treatment of persistent male stress incontinence. Today, several sling systems are available. Well-known complications of all sling systems are infections, erosion, residual urine/urinary retention, de novo urgency, and postoperative pain. DISCUSSION: Compared to retropubic implanted adjustable sling systems or functional slings, pain is more common after transobturatoric implantation of adjustable sling systems. Early postoperative pain is very common. In contrast, persistent pain is rare. However, the treatment of persistent pain is a large challenge for urologists and patients. There are no recommendations for diagnostic workup or treatment. RESULTS: After pain classification, pain management should be started with nonsteroidal anti-inflammatory drugs and/or tricyclic antidepressive agents, if necessary treatment escalation with a weak opioid and if not effective interventional procedures should be performed. Sling explantation is only necessary in rare cases.

[Hydronephrosis after suburethral sling implantation: diagnosis and operative management in men]. / Harnstauungsniere nach suburethraler Bandeinlage : Diagnostik und operatives Management beim Mann.

Readjustable suburethral sling procedures have become established as a standard method for therapy of postoperative urinary stress incontinence in men. Due to the silicone construction revision after implantation of Argus ™ slings can be carried out without problems even after a long indwell time. In the case presented correction of sling-related hydronephrosis due to incorrect positioning of the Argus ™ sling is demonstrated. Surgical correction was possible without explantation or exchanging the system and ensuring a good functional outcome.

Expression of cytochrome P450 enzymes CYP1A1, CYP1B1, CYP2E1 and CYP4B1 in cultured transitional cells from specimens of the human urinary tract and from urinary sediments.

Expression of cytochromes P450 CYP1A1, CYP1B1, CYP2E1 and CYP4B1 was analysed on the transcript level in human urothelial cells obtained by various methods. As a source of urothelial cells, exfoliated cells in urine samples were used. Their expression profiles were determined either immediately after centrifugal enrichment (n=4) or after their cultivation and propagation (n=8). Another source of urothelial cells were ureter specimens from surgical subjects (n=4). Generally, expression was most prominent for CYP1B1 and CYP4B1 among the CYP transcripts analysed. CYP1B1 mRNA was detected in all samples investigated except for one ureter specimen. CYP4B1 mRNA was present in cell cultures from three out of eight healthy subjects, in three out of four directly investigated urinary sediments and in the cells of all five ureter specimens of four donors investigated after resection and subsequent cell culture. In most cases, CYP2E1 transcript levels were lower than those of CYP1B1 and CYP4B1. CYP2E1 mRNA was detected in cell cultures of six out of eight healthy subjects, in one out of four urinary sediments and in three out of five ureter specimens. CYP1A1 mRNA was clearly observed only in cells from resected ureters. In cell cultures the relative mRNA expression levels varied with subjects interindividually, intraindividually and also during the time of cell culture. The study demonstrates constitutive mRNA expressions of xenobiotic metabolising CYP enzymes in human urothelial cells obtained by different methods. In particular, transcripts of CYP1B1 and CYP4B1 are present, coding for enzymes which are active in the metabolism of polycyclic aromatic hydrocarbons and arylamines, respectively.

Interferon-alpha 2b instillation prophylaxis in superficial bladder cancer--a prospective, controlled three-armed trial. Project Group Bochum--Interferon and Superficial Bladder Cancer.

Sixty-seven patients with recurrent pTa G1-G3 to pT1 G1-G3 tumors were randomized into three groups receiving either Intron A at 10 MU/instillation, Intron A at 10 MU and mitomycin C (MMC) at 20 mg/instillation or MMC at 20 mg/instillation. After a mean follow up of 6.2 months no tumor recurrence has been seen in the group receiving combined therapy, whilst four out of 22 in the interferon group and five out of 23 in the MMC group suffered a recurrence. Side effects were slight. These preliminary results suggest that a combination of the two drugs is more effective than either drug alone.

Perioperative antibiotic prophylaxis in ureteroscopic stone removal.

OBJECTIVE: This study shall settle the question whether a perioperative single shot prophylaxis in connection with a ureteroscopic stone removal has an influence on the rate of postoperative urinary tract infections (UTIs) and inflammable complications or not. METHODS: 113 patients were included in this prospective randomized study. In 57 patients 250mg Levofloxacin p. o. was given approximately 60 prior ureteroscopy, 56 patients had no prophylaxis. The evaluation of all data which were processed electronically was carried out with the help of a standardised questionnaire. RESULTS: Postoperatively symptomatic urinary tract infections or inflammable complications of the urogenital tract were found in neither of the two groups. In the group without prophylaxis, the rate of the postoperative significant bacteriurias was significantly higher than in the group with prophylaxis (7 patients [12.5%] vs. 1 patient [1.8%]) (p=0.026). In six cases there was an E. coli bacteriuria; additionally a Kl. pneumoniae and a not specified Staphylococcus bacteriuria were detected in further cases. CONCLUSION: Single shot prophylaxis using 250 mg Levofloxacin p. o. can be considered as cheap, the patient not burdened and regarding the missed selection pressure to nosocomial pathogens the preferred manner of perioperative antibiotic prophylaxis in ureteroscopic stone removal. In addition perioperative single shot prophylaxis may be beneficial in case of an unexpected intraoperative complication like e.g. ureter perforations.

Rupture of ileal neobladder due to urethral obstruction by mucous plug.

We report a case of ileal neobladder rupture after radical cystectomy due to mucus obstruction of the bladder neck. Since mucus production in bowel neobladders cannot be sufficiently influenced pharmacologically, patients with a continent urinary diversion connected to the urethra should learn self-catheterization.

Nosocomial infections after transurethral prostatectomy.

In spite of new techniques transurethral prostatic resection (TURP) remains the gold standard in operative therapy of benign prostatic hyperplasia. There are some suggested risk factors for TURP which could affect the rate of postoperative complications. In this prospective study we investigated whether the suggested risk factors have any relevance for the occurrence of nosocomial urinary tract infections (UTIs) after TURP and what kind of influence these infections may have on the clinical course. In general we found no statistically significant influence on the analyzed risk factors for the incidence of nosocomial UTIs. On the other hand in the group of patients with nosocomial UTIs both the rate of other nosocomial infections (i.e. septicemia) and the rate of inflammatory complications were significantly higher compared to the group without postoperative UTIs (p < 0.001). We conclude that all patients undergoing TURP should receive perioperative antimicrobial prophylaxis.