Health-economic analysis of real-time continuous glucose monitoring in people with Type 1 diabetes.

AIM: To evaluate the clinical benefits and cost-effectiveness of the sensor-augmented pump compared with self-monitoring of plasma glucose plus continuous subcutaneous insulin infusion in people with Type 1 diabetes. METHODS: The CORE Diabetes Model was used to simulate disease progression in a cohort of people with baseline characteristics taken from a published meta-analysis. Direct and indirect costs for 2010-2011 were calculated from a societal payer perspective, with cost-effectiveness calculated over the patient's lifetime. Discount rates of 3% per annum were applied to the costs and the clinical outcomes. RESULTS: Use of the sensor-augmented pump was associated with an increase in mean discounted, quality-adjusted life expectancy of 0.76 quality-adjusted life years compared with continuous subcutaneous insulin infusion (13.05 ± 0.12 quality-adjusted life years vs 12.29 ± 0.12 quality-adjusted life years, respectively). Undiscounted life expectancy increased by 1.03 years for the sensor-augmented pump compared with continuous subcutaneous insulin infusion. In addition, the onset of complications was delayed (by a mean of 1.15 years) with use of the sensor-augmented pump. This analysis resulted in an incremental cost-effectiveness ratio of 367,571 SEK per quality-adjusted life year gained with the sensor-augmented pump. The additional treatment costs related to the use of the sensor-augmented pump were partially offset by the savings attributable to the reduction in diabetes-related complications and the lower frequency of self-monitoring of plasma glucose. CONCLUSIONS: Analysis using the CORE Diabetes Model showed that improvements in glycaemic control associated with sensor-augmented pump use led to a reduced incidence of diabetes-related complications and a longer life expectancy. Use of the sensor-augmented pump was associated with an incremental cost-effectiveness ratio of 367,571 SEK per quality-adjusted life year gained, which is likely to represent good value for money in the treatment of Type 1 diabetes in Sweden.

Urinary retention: benefit of gradual bladder decompression - myth or truth? A randomized controlled trial.

INTRODUCTION: Urinary retention is a common emergency requiring immediate catheterization. Gradual decompression (GD) of the extended bladder is believed to minimize the risk of complications such as bleeding or circulatory collapse, but to date it has not been compared with rapid decompression (RD) in controlled trials. MATERIALS AND METHODS: Male patients presenting with urinary retention (n = 294) were randomized to rapid or gradual catheterization. For the latter, the transurethral catheter was clamped for 5 min after every 200-ml outflow until the bladder was completely empty. Patients were monitored for at least 30 min thereafter with regular checks of vital signs and presence of macroscopic hematuria. RESULTS: Of 294 patients, 142 (48.3%) were randomized to the GD and 152 (51.7%) to the RD group. Both groups showed no statistically significant difference with regard to age, anticoagulation treatment, catheter size and material, or volume retained. Hematuria occurred in 16 (11.3%) of the GD and 16 (10.5%) of the RD group; 6 patients in the former and 4 in the latter required further treatment. No circulatory collapse occurred. We noted a decrease in the previously raised blood pressure and heart rate in both groups, although without clinical significance. CONCLUSION: In this first randomized trial, no statistically significant difference was noted between gradual and rapid emptying of the bladder for urinary retention. Gradual emptying did not reduce the risk of hematuria or circulatory collapse. Therefore, there is no need to prefer gradual over rapid emptying, which is both easy and safe.

Ureteral substitution with reconfigured colon: long-term followup.

PURPOSE: Long defects in the mid and upper ureter are not amenable to end-to-end reconstruction. Therefore, we present the long-term results of our technique with reconfigured colon segments. MATERIALS AND METHODS: Between June 1998 and July 2008, 14 patients underwent ureteral replacement at our institution with reconfigured colon. In 4 patients the substitute was anastomosed to the skin as a modified colon conduit. In 10 patients it was interposed with anastomosis to the ureter in 4, to the bladder in 5 and to the afferent loop of an ileal bladder substitute in 1. RESULTS: At a median followup of 52.4 months (range 7 to 136) excellent renal function was confirmed in 10 of 14 patients. Now at a median followup of 95.8 months (range 38 to 136) 6 patients are alive, all without an indwelling stent and with no sign of obstruction of the ureteral replacement. Metabolic disorders, mucus obstruction and stricture or adhesive ileus were absent during followup. In this series death was unrelated to the procedure. In 7 patients 11 specific reinterventions were necessary including 4 cases of prolonged stenting after surgery, 3 which required secondary drainage, 3 cases of urinary tract infection at 4 weeks and 3 and 112 months, and 1 acute bowel obstruction due to peritoneal carcinosis. CONCLUSIONS: Reconfigured colon segments can be used successfully to replace long ureteral defects. The advantages are use in patients with impaired renal function and lack of small intestine, proximity of the colon to the ureter, optimal cross-sectional diameter of the graft and less intraperitoneal surgical trauma than with ileal substitutes.

Associated findings and complications of retroperitoneal fibrosis in 204 patients: results of a urological registry.

PURPOSE: We studied the frequency of associated findings and complications of retroperitoneal fibrosis in a large clinical collective of urological patients. MATERIALS AND METHODS: All urology departments in Germany were invited to participate in a registry of patients with retroperitoneal fibrosis, for which a data sheet with more than 200 questions was developed. RESULTS: As of March 2010 a total of 204 patients were registered. The male-to-female ratio was 2.1:1 and the average age at onset was 55.6 years. In 123 cases (60.3%) the diagnosis was confirmed by histopathology. Coexisting autoimmune diseases were found in 9.8% of patients, consisting mainly of thyroid disorders. Coexisting fibrosis was detected in 3.4% of the patients and 73.9% of those queried were active smokers. Of 176 patients for whom data on therapy were available 123 received monotherapy and 41 received combination therapy for a mean of 12.1 months (12 received none), while 87 underwent a total of 103 operative procedures. Hydronephrosis was the most frequent complication in 95.6% of patients. Atrophic kidney from undetected hydronephrosis appeared in 46 patients (22.5%) and in 4 bilateral damage necessitated dialysis. Complications from vascular obstruction were observed in 27.5% of patients. Large bowel obstruction requiring colostomy occurred in 4 patients (2.0%). CONCLUSIONS: Patients with retroperitoneal fibrosis often first present to urology departments upon referral for hydronephrosis. In this series at least 1 kidney appeared to be irreversibly damaged in more than 20% of patients. Urologists should be mindful of the role of smoking role as a risk factor, complications arising from vascular and large bowel obstructions, and the possible association of retroperitoneal fibrosis with autoimmune disease.

[Retroperitoneal fibrosis]. / Retroperitoneale Fibrose.

Retroperitoneal Fibrosis (RPF) is a rare disease with peak incidence in the fifth to seventh decades of life. Its etiology remains to a great extent unclear; however, many characteristics of the disease suggest an autoimmune origin. Distinction is made between primary/idiopathic and secondary RPF. Symptoms may be general/nonspecific or localized (due to replacement or compression of organs). In addition to patient history, laboratory analysis and radiologic examinations, diagnosis often requires biopsy taken from the area affected. After restoring the function of involved (hollow) organs, medical therapy with prednisone, immunosuppressive drugs or tamoxifen is aimed at converting active disease to stable disease. However, some patients require ureteral surgery due to unsuccessful treatment. Life-long follow-up of patients is necessary since RPF can show a chronically relapsing course.

[Treatment of specific complications of locally advanced prostate cancer]. / Behandlung von spezifischen Komplikationen des lokal fortgeschrittenen Prostatakarzinoms.

Despite improved screening methods and earlier detection of prostate carcinoma, the complications of locally advanced disease remain a challenge for urologists. The spectrum of possible complications includes subvesical obstruction, hydronephrosis, hematuria, pain, and local invasion of adjacent organs. Urinary diversion, palliative transurethral resection of the prostate, and endoscopic diathermy are classic procedures. Urethral stenting, laser evaporation, and selective arterial embolization are alternate approaches for treating these complex cases. Cystoprostatectomy and pelvic exenteration are ultimate options for patients with chronic pain and debilitating local symptoms.

Diffusion-weighted MRI and PET-CT in the follow up of chronic periaortitis.

Aim of the present study is to compare magnetic resonance imaging (MRI) and positron emission tomography (PET) parameters in the follow up of chronic periaortitis (CP), with a focus on changes in the apparent diffusion coefficient (ADC) and standardized uptake values (SUV). 127 patients with CP were treated in our urology between 2007 and 2017. We identified 14 patients with parallel abdominal MRI and PET-CT examinations before therapy and in the follow up resulting in a total of 56 examinations. Relative contrast uptake and diffusion-weighted MRI parameters were compared to SUV in the corresponding PET-CT examinationsand laboratory infection markers. All examined MRI and PET-CT parameters showed significant changes between basis and follow-up examinations. Median ADC values increased significantly (p < 0.001) in the follow up. SUVmax and the other MR parameter (contrast uptake, DWI-signal) declined significantly. We observed a strong negative correlation between ADC and SUVmax (rho: - 0.61; p < 0.001). In addition, we found an inverse correlation of ADC with the inflammation markers ESR (rho: - 0.64; p < 0.001) and CRP (rho: - 0.54; p = 0.001). MRI and PET-CT showed comparable results in the individual follow up of CP and compared to laboratory inflammation markers. Our data support MRI as first imaging modality due to absent radiation and the necessity of repetitive follow-up examinations in patients with CP.

[Retroperitoneal fibrosis]. / Retroperitoneale Fibrose.

Retroperitoneal fibrosis (RPF) is characterised by inflammatory fibrotic processes affecting the retroperitoneal structures. Its prevalence of 1 - 2/200,000 makes it a rare disease. To date, there are no guidelines for the diagnosis of or therapy for the disease. If untreated, the disease may be fatal. In 2006, the Department of Urology of the HELIOS Klinikum Wuppertal undertook to establish a nationwide patient registry, which would facilitate prospective therapy trials and the drafting of recommendations for diagnostic procedures. The pathogenesis of the disease is still unclear. Since some RPF-patients present with associated autoimmune diseases, autoimmune processes are suspected to play a role in causing the disease. The presence of autoantibodies and histological similarities with vasculitis support this hypothesis. Following initial general symptoms, patients display localised symptoms (flank pain, leg oedema, abdominal discomfort), caused by the displacing effect of the fibrotic plaques. Laboratory tests show elevated ESR and C-reactive protein and in some cases a moderate anaemia. Histological examinations should be undertaken to rule out the presence of malignant tumours. Radiological diagnostics (excretory urography, CT, MRI) show a retroperitoneal mass which blocks, compresses and displaces, completely or in part, the large vessels and the ureter. Initial therapy aims at restoring the function of the affected hollow organs through the application of (ureteric) stents, followed by immunosuppressive therapy. If drug therapy is unsuccessful, surgical procedures will follow to protect the ureter from compression. In some cases, ureteral replacement or an autotransplant of the kidney may be necessary. Life-long observation of the patients is necessary, as the disease may be chronic and relapsing. Interdisciplinary and nationwide cooperation is of crucial importance to further investigate this disease.

[New (and old) aspects of retroperitoneal fibrosis]. / Neue (und alte) Aspekte der retroperitonealen Fibrose.

Retroperitoneal fibrosis (RPF) is an uncommon chronic inflammatory disease of the rear abdomen and it is commonly associated with the complication of uni- or bilateral hydronephrosis. Despite the rarity of this disease, multiple publications concerning etiology, diagnosis, therapy monitoring and both medical and surgical therapy have been published in recent years. Recent research has focused on asbestos exposure as a possible risk factor, the meaning of IgG4-associated RPF, measuring disease activity using different radiological and nuclear medicine procedures, and new approaches to medical therapy. Goals of treatment were characterized as the correct diagnosis, preservation of renal function and freedom from stents, steroids and pain. On the basis of these goals, the most important insights and developments of the last 5 years regarding RPF are presented.

[Ureteral stricture as a late complication of radiotherapy : Possible treatment options]. / Radiogene Harnleiterstrikturen : Mögliche Therapieoptionen.

Ureteral strictures are uncommon complications of radiotherapy which are often recognized late. Their consequences range from harmless dilatation of the ureter to loss of renal function and potential life-threatening urosepsis.Therapy of radiogenic ureteral stricture is a challenging task for every urologist. Several surgical strategies including minimally invasive procedures, reconstruction and partial or complete replacement of the ureter are available.This article provides an overview of the various options in the treatment of radiogenic stricture of the ureter, focusing on the use of ileum and colon segments for ureteral substitution.

[Diagnosis and treatment of retroperitoneal fibrosis]. / Diagnostik und Therapie der retroperitonealen Fibrose.

Retroperitoneal fibrosis (RPF) is a rare chronic inflammatory disease of the posterior abdominal cavity. Hydronephrosis due to extrinsic compression of the ureter is the most frequent complication of the disease, which is why patients are often treated by urologists.On the basis of checklists the most important and fundamental facts of diagnosis (symptoms, hydronephrosis, laboratory parameters, diagnostic radiology, histology, renal function and measuring disease activity) and therapy (goals of therapy, medical and surgical therapy) are presented.

[Retroperitoneal fibrosis: development of a biomarker profile for diagnosis and therapy monitoring]. / Retroperitoneale Fibrose : Entwicklung eines Biomarkerprofils zur Diagnostik und Verlaufskontrolle.

INTRODUCTION: Retroperitoneal fibrosis (RPF) is a rare chronic inflammatory disease which is characterized by fibrotic tissue in the retroperitoneal space. There have only been a few studies on serum markers of this disease. The main goal of the current investigation was to identify biological markers which are increased in the serum of patients suffering from RPF and which may correlate with the extent of fibrosis. MATERIAL AND METHODS: The serum of 42 patients with primary and yet untreated retroperitoneal fibrosis was examined for biomarkers known to be specific for fibrotic diseases and compared to a control group. In addition, patients were stratified according to the extent and volume of the retroperitoneal mass using cross-sectional imaging. To estimate the discriminatory power of the evaluated biomarkers, receiver operating characteristic (ROC) curves were created. RESULTS: Independent of the extent of fibrosis, calprotectin, fibrinogen, osteopontin, matrix metallopeptidase 9 (MMP-9), tenascin C and TIMP metallopeptidase inhibitor 1 (TIMP-1) were significantly increased (p<0.01) in patients suffering from RPF compared to the control group. Connective tissue growth factor (CTGF) was significantly elevated (p<0.01) in patients with high RPF burden only but monocyte chemoattractant protein 1 (MCP-1) and heart-type fatty acid binding protein (H-FABP) showed no increase in serum levels. The discriminatory power of these parameters was ranked by the ROC analysis which demonstrated an area under the curve (AUC) >0.87 for MMP-9, TIMP-1, osteopontin, tenascin C, asymmetric dimethylarginine (ADMA), fibrinogen and calprotectin and an AUC <0.64 for MMP-2, CTGF, H-FABP and MCP-1. CONCLUSION: Several biomarkers of fibrogenesis were significantly elevated in patients suffering from RPF as compared to a control group. These biomarker candidates will be further evaluated for their potential to allow a differentiation between other diseases or if they could be used for disease monitoring.

[Therapy of retroperitoneal fibrosis: functional therapeutic outcome]. / Therapie der retroperitonealen Fibrose : Funktionelle Behandlungsergebnisse.

BACKGROUND: The most frequent complication of retroperitoneal fibrosis (RPF) is an extrinsic compression of the ureter resulting in hydronephrosis. Because of the rareness of this uncommon chronic inflammatory disease, therapeutic results concerning the treatment of the obstructive uropathy are often known only for small study groups. MATERIAL AND METHODS: The Else Kröner-Fresenius registry is a nationwide register of patients suffering from RPF in which all disease-related data are prospectively recorded. We performed a retrospective analysis of treatment outcome of different therapy strategies for all patients who underwent standardized treatment in our department since 2007. RESULTS: From April 2007 to January 2014 a total of 97 patients with RPF were treated in our department. The mean age was 54.9 years and the male to female ratio was 3.2:1 (74 males and 23 females). Assessment of 85 out of 97 cases revealed 78 patients and 118 renal units with hydronephrosis. Of these patients 46 received prednisolone, 35 patients tamoxifen and 4 patients a combination therapy. Successful removal of double J stents was possible in 49 out of the 78 cases (62.8%) and in 72 out of 118 renal units (61.0%). Of the patients 26.9% received final surgical treatment of ureter compression and 7.7% of patients were permanently treated with a double J stents. Patients treated with prednisolone were significantly younger (p=0.040) and decided for surgical therapy significantly earlier (p=0.041). Otherwise there were no differences in functional outcome of patients treated with either prednisolone or tamoxifen. CONCLUSION: Removal of double J stents was possible in 63% of patients regardless of the medicinal approach to therapy, which supports the strategy of using medicinal treatment before the application of surgical solutions. Nevertheless, surgical interventions were necessary in more than 25% of cases.

Diffusion-weighted MRI in the follow-up of chronic periaortitis.

OBJECTIVE: To evaluate the usefulness of diffusion-weighted MRI (DWI) for the assessment of the intraindividual follow-up in patients with chronic periaortitis (CP) under medication. METHODS: MRI data of 21 consecutive patients with newly diagnosed untreated disease were retrospectively examined before and after medical therapy, with a median follow-up of 16 weeks. DWI parameters [b800 signal, apparent diffusion coefficient (ADC) values] of the CP and psoas muscle were analysed together with the extent and contrast enhancement. Pre- and post-treatment laboratory inflammation markers were acquired parallel to each MR examination. RESULTS: Statistically significant lower b800 signal intensities (p ≤ 0.0001) and higher ADC values (p ≤ 0.0001) were observed after medical treatment within the fibrous periaortic tissue. Extent and contrast enhancement of the CP showed also a statistically significant decrease (p ≤ 0.0001) in the follow-up examinations, while the control parameters within the psoas muscle showed no differences. CONCLUSION: DWI seems to be a useful method for the evaluation of response to treatment without contrast agents. The technique may be helpful in the assessment of disease activity to guide further therapeutic strategies. ADVANCES IN KNOWLEDGE: DWI detects significant differences in the intraindividual follow-up of CP under medical therapy.

Diffusion-weighted MRI in the follow-up of chronic periaortitis.

OBJECTIVE:: To evaluate the usefulness of diffusion-weighted MRI (DWI) for the assessment of the intraindividual follow-up in patients with chronic periaortitis (CP) under medication. METHODS:: MRI data of 21 consecutive patients with newly diagnosed untreated disease were retrospectively examined before and after medical therapy, with a median follow-up of 16 weeks. DWI parameters [b800 signal, apparent diffusion coefficient (ADC) values] of the CP and psoas muscle were analysed together with the extent and contrast enhancement. Pre- and post-treatment laboratory inflammation markers were acquired parallel to each MR examination. RESULTS:: Statistically significant lower b800 signal intensities (p ≤ 0.0001) and higher ADC values (p ≤ 0.0001) were observed after medical treatment within the fibrous periaortic tissue. Extent and contrast enhancement of the CP showed also a statistically significant decrease (p ≤ 0.0001) in the follow-up examinations, while the control parameters within the psoas muscle showed no differences. CONCLUSION:: DWI seems to be a useful method for the evaluation of response to treatment without contrast agents. The technique may be helpful in the assessment of disease activity to guide further therapeutic strategies. ADVANCES IN KNOWLEDGE:: DWI detects significant differences in the intraindividual follow-up of CP under medical therapy.

[Urethral pain syndrome: fact or fiction--an update]. / Das Urethralsyndrom: Fakt oder Fiktion--ein Update.

BACKGROUND: Urethral pain syndrome is a symptom complex including dysuria, urinary urgency and frequency, nocturia and persistent or intermittent urethral and/or pelvic pain in the absence of proven infection. These symptoms overlap with several other conditions, such as interstitial cystitis bladder pain syndrome and overactive bladder. Urethral pain syndrome may occur in men but is more frequent in women. DIAGNOSTIC: The exact etiology is unknown but infectious and psychogenic factors, urethral spasms, early interstitial cystitis, hypoestrogenism, squamous metaplasia as well as gynecological risk factors are discussed. These aspects should be ruled out or confirmed in the diagnostic approach. Despite the assumption of a multifactorial etiology, pathophysiologically there is a common pathway: dysfunctional epithelium of the urethra becomes leaky which leads to bacterial and abacterial inflammation and ends in fibrosis due to the chronic impairment. THERAPY: The therapeutic approach should be multimodal using a trial and error concept: general treatment includes analgesia, antibiotics, alpha receptor blockers and muscle relaxants, antimuscarinic therapy, topical vaginal estrogen, psychological support and physical therapy. In cases of nonresponding patients intravesical and/or surgical therapy should be considered. The aim of this review is to summarize the preliminary findings on urethral pain syndrome and to elucidate the diagnostic and therapeutic options.

[Avoidance and management of complications in open surgical ureter reconstruction]. / Komplikationsvermeidung und -management bei offenen Harnleiterrekonstruktionen.

Open surgical reconstruction of the ureter is a urological procedure with a potentially high risk of complications. The correct selection of patients and time of operation are important aspects regarding the treatment strategy. Position and length of the affected ureter segment to be reconstructed determine the surgical intervention possibilities. The psoas hitch procedure is a well-established technique for distal reconstruction of the ureter where most iatrogenic injuries occur. In more proximal or complex defects, several procedures are available. Partial or complete replacement of the ureter with bowel is still considered the standard for bridging long ureteral defects but is accompanied with higher intra- and postoperative complication rates. In specific patients and situations, autotransplantation of the kidney and subcutaneous pyelovesical bypasses are clinical options. Using mucosal grafts or tissue engineering may be new therapeutic prospects to cover ureteral defects but the clinical impact still needs to be clarified. All therapeutic strategies share the fact that great surgical expertise and experience are necessary as the operative technique must be mastered to avoid severe complications.

[Impact of operator experience on TURB of high-grade non-muscle-invasive bladder cancer--analysis of 254 second resections at a university teaching hospital]. / TURB--Welche Bedeutung hat die Erfahrung des Operateurs bei high grade-Tumoren der Harnblase? Analyse von 254 Nachresektionen an einer universitären Ausbildungsklinik.

INTRODUCTION: In departments with urological training of residents, part of the TURB procedures are performed as "teaching surgery". Does resection quality and early recurrence depend on the operator's experience? PATIENTS AND METHODS: From July 2007 to February 2012 254 second resections (TURB) after Ta high-grade and T1 high-grade bladder tumours were performed at our institution. The surgeons were stratified into "junior residents" (first and second year of training), "experienced residents" (3rd-5th year of training), board certified urologists, consultants and chief surgeons. We analysed the risk of recurrence at second resection and characteristics of the initial TURB. RESULTS: 87 patients presented with a Ta high-grade tumour (34.3%) and 167 had a T1 high-grade lesion (67.7%). Most TURBs were performed by "experienced residents" (3rd-5th year) and the chief of department. The recurrence rate at second resection was 52.4%. A significant association with the recurrence rate was shown for the number of initial tumours, size and T-stage. No association was found for the training level of the surgeon. Additionally, there was no different detrusor rate for the surgeons, as a parameter for a correct, muscle-deep TURB. A bias that surgeons in training had more favourable tumours (solitary, less than 3 cm) could be excluded. CONCLUSIONS: In our data detrusor rate and recurrence risk at second resection are independent of the surgeon's experience. The results of "teaching-TURBs" are not inferior compared to TURBs performed by board certified urologists or consultants under the conditions of undisturbed communication and personal supervision.

[Premature ejaculation in urological routine practice]. / Die Ejaculatio praecox in der urologischen Praxis.

Premature ejaculation is a frequent male sexual complaint or sexual disturbance found in urological practices and outpatient units. The frequency in the individual practices varies considerably. In large studies the prevalence is strongly dependent on the definition and ranges between 3% and 25%. Subjectively, the inability to delay ejaculation and the distress resulting from it, is relevant for the patient and his partner. Intravaginal ejaculation latency time (IELT) is used as an objective parameter. Nevertheless, in the everyday routine practice this objective parameter is not practical. Clinically 2 questionnaires have asserted themselves (Premature Ejaculation Profile and Index of Premature Ejaculation). Studies have shown that the self-assessment of patients correlates relatively well with the objective IELT measured by means of a stopwatch. Beside topical anaesthetics and elective serotonin reuptake inhibitors (SSRI), especially Dapexetine which has been approved in Germany since 2009, are treatment options. These drugs differ particularly in their use (daily or on-demand) and their effectiveness (measured by x-fold increase of IELT). This article deals with the clinical approach to EP. Beside the definition, prevalence, aetiology and neurophysiology of EP, the different pharmacological therapies as well as the guidelines of the International Society for Sexual Medicine are discussed.