[The "right" patient for implant surgery in urology : Why patient selection, informed consent, and communication are so important for patient satisfaction]. / Der "richtige" Patient für die Implantatchirurgie in der Urologie : Warum Patientenselektion, Aufklärung und Patientenkommunikation so wichtig für die Patientenzufriedenheit sind.

In implant surgery for erectile dysfunction and urinary incontinence, adequate patient selection is essential for postoperative therapy success. Several scientific studies report patient satisfaction rates for penile implants and artificial urinary sphincter implantation of over 90%. Nevertheless, studies also report, that between 5 and 30% of the patients are not satisfied with the result of their operation. Sufficient patient information and consent prior surgical procedure in urological prosthetics are a key determinant for later patient satisfaction and therapy success. Diligent assessment of realistic expectations, possible complications, and risks must be made. Unrealistic and exaggerated expectations need to be met and discussed with the patient. Therefore adequate physician-patient communication is essential. Especially in the case of surgical revision or for patients with risk factors, the probability of complications is higher and may significantly increase later dissatisfaction. Also, the involvement of the partner plays a major role in later patient satisfaction in urological implant surgery. Finally, there is a group of patients for which the risk of later dissatisfaction is particularly high. These are patients with compulsive/obsessive behavior, unrealistic expectations, patients after revision surgery, self-entitled patients, as well as those patients who deny the extent of their illness, visit multiple surgeons (surgeon hopping) or have psychiatric illnesses. These patients are referred to with the acronym "CURSED" patients.

[Evidence-based drug therapy for male infertility]. / Evidenzbasierte medikamentöse Therapieansätze der Infertilität.

Evidence-based drug therapy for male infertility is often difficult because 30% of all cases of male infertility are classified as idiopathic, and another 30% need surgical treatment. Without knowledge of the underlying pathology, there is no foundation for a specific and causal treatment. Most of the currently used drug therapies are empirical at best; moreover, many of the studies on drug treatment for male infertility do not fulfill the required standards of evidence-based medicine (randomized, prospective, placebo-controlled), and the statistical endpoints used (sperm quality, pregnancy rate, baby take-home rate) are not uniform. This article, which is based on a literature survey and the current guidelines concerning drug therapy for male infertility, covers the most common treatment options. Regarding the currently insufficient scientific data for drug therapy and dietary supplements on male infertility, there is a demand for critical indications that take into consideration the possible side effects and the treatment costs. In the case of insufficient drug therapy for male infertility, reproductive medicine seems to be promising.

Can written information material help to increase treatment motivation in patients with erectile dysfunction? A survey of 1188 men.

Although erectile dysfunction (ED) prevalence is high, patients and physicians often have problems discussing this issue. This study examines whether written information material increases motivation to seek treatment in patients with ED. For the study, persons were able to order information material about sexual problems within the context of a public campaign. From a total of 70,000 responders, 8000 persons were asked to fill out an epidemiological questionnaire. The response rate yielded 18.4%, the data of 1188 men with ED were analyzed. As a result of the information material, 28.3% of the untreated men intended to seek treatment and 38.5% of the men who had not spoken with their physician about their problem, planned to do so now. Nearly all responders were satisfied with the information material. These data reflect the usefulness of written information for men with ED. It not only serves as an informational source for patients but may also encourage them to seek treatment.

[Von Hippel-Lindau disease. Interdisciplinary patient care]. / Von-Hippel-Lindau-Erkrankung. Interdisziplinäre Patientenversorgung.

Von Hippel-Lindau disease is an important hereditary tumor syndrome with a clear option for effective treatment if diagnosed in time. Interdisciplinary cooperation is the key to successful management. Major components of the disease are retinal capillary hemangioblastomas, hemangioblastomas of cerebellum, brain stem and spine, renal clear cell carcinomas, pheochromocytomas, multiple pancreatic cysts and islet cell carcinomas, tumors of the endolymphatic sac of the inner ear, and cystadenomas of the epididymis and broad ligament. A well structured screening program should be performed at yearly intervals.

[Erectile dysfunction : Current diagnostics and treatment]. / Erektile Dysfunktion : Aktuelle Diagnostik und Therapie.

Erectile dysfunction is a medical disease with extensive influence on the quality of life and well-being of patients and their female or male partners. Nowadays, most of the underlying pathological factors are well known. The general medical history with the question of possible risk factors and the specific sexual history play the most important roles in the guideline-based diagnostics. In addition, a thorough clinical examination and specific laboratory tests should be carried out. Phosphodiesterase 5 (PDE-5) inhibitors, vacuum devices, injection therapy and penile prostheses are the options for an evidence-based and individual treatment of affected patients. The success rates are high in most cases. Every urologist, andrologist and practitioner of sexual medicine should have detailed knowledge in this field.

Treatment expectations of men with ED and their female partners: an exploratory qualitative study based on grounded theory.

Erectile dysfunction (ED) can impair the quality of life and the relationship. An early treatment is necessary to avoid the development of comorbid complaints. To arise the help-seeking behavior and to improve the treatment of affected men, it is necessary to be aware of the treatment expectations. The objective of this study was to investigate the treatment expectations of men with ED and their female partners. This is an explorative qualitative study using semistructured telephone interviews with 12 men with ED and their female partners. Interviews were tape-recorded, transcribed and analyzed on the basis of the grounded theory. We could identify various treatment expectations, which could be differentiated into expectations according to the conditions (for example, low costs and an early access), the handling of the practitioner (for example, showing interest and taking the patient seriously or incorporate the female partner), the treatment itself (for example, clearing the causes and helpful medication) and the treatment outcome (for example, having no ED and more sexual desire). Considering the identified expectations could increase treatment motivation and compliance. We derive five theses from our data, how to implement our findings.

[Specialized intestinal metaplasia of the distal esophagus in gastroesophageal reflux disease: prevalence and clinico-demographic features]. / Metaplasia intestinal especializada de esôfago distal na doença do refluxo gastroesofágico: prevalência e aspectos clínico-epidemiológicos.

BACKGROUND: Specialized intestinal metaplasia can be categorized according endoscopic and histological findings in long segment Barrett, short segment Barrett and specialized intestinal metaplasia of cardia. Barrett's esophagus is an acquired disease that is found in about 10%-13% of patients undergoing endoscopy for symptoms of gastroesophageal reflux disease and it is well established as predisposing to esophageal adenocarcinoma. The columnar epithelium with goblet cells replaces the normal squamous epithelium. OBJECTIVE: To determine the prevalence and clinical-demographic characteristics of specialized intestinal metaplasia of distal esophagus in the gastroesophageal reflux disease. METHODS: From April to October 2002, 402 patients referred to upper endoscopy due gastroesophageal reflux disease were evaluated through of a symptom questionnaire about clinical and demographic features and submitted to upper endoscopy with four-quadrant biopsies 1 cm below escamocolumnar junction. RESULTS: Eighteen point four percent of patients had specialized intestinal metaplasia, 0.5% long segment Barrett esophagus, 3.2% short segment Barrett's esophagus and 14.7% specialized intestinal metaplasia of cardia. Patients with Barrett's esophagus showed a tendency to be male and specialized metaplasia of cardia to be female. All patients with Barrett's esophagus were white. There was not association between symptoms of gastroesophageal reflux disease and specialized intestinal metaplasia, but patients with Barrett's esophagus showed a tendency to have symptoms over 5 years and had more hiatal hernia and esophagitis. The use of alcohol and tobacco was not related to the presence of specialized intestinal metaplasia. CONCLUSIONS: Barrett's esophagus was more related to the male gender, gastroesophageal reflux disease symptoms for 5 years or longer, more intense esophagitis and hiatal hernia, but was not related to the use of tobacco and alcohol.

Pericardial effusion with cardiac tamponade as a form of presentation of primary hypothyroidism.

The authors describe a case of pericardial effusion accompanied by cardiac tamponade caused by primary hypothyroidism. Diagnosis was made by exclusion, because other causes of cardiac tamponade are more frequent. Emergency treatment of cardiac tamponade is pericardiocentesis (with possible pericardial window), and, after stabilization, performance of hormonal reposition therapy with L-thyroxin.

Treatment motivation of men with ED: what motivates men with ED to seek professional help and how can women support their partners?

Although ED can impair sexual satisfaction as well as the quality of partnership and life, men affected often avoid seeking treatment. There is growing evidence that women have an influence on their partner's help-seeking behavior. This qualitative study examined men with ED and their female partners in order to detect motivational factors for men to seek treatment and motivational actions of the women to support their partners. Twelve couples took part in a semi-structured telephone interview, which was performed separately in men and women. Analysis was on the basis of the Grounded Theory. The identified motivational factors could be divided into extrinsic (for example, media, female partner) and intrinsic (for example, desire to clarify the cause of the ED, hope for improvement) factors. Women can support their partners in treatment-seeking through various motivational actions such as talking with each other, showing interest and dealing actively with the problem, appealing to the male self-esteem, supporting the doctor's visit, forcing the treatment, active cooperation and participation in the treatment or initiating sexual intercourse. On the basis of these findings, recommendations for women were developed to support their partners and increase the probability of help-seeking behavior.

Nephron sparing surgery in von Hippel-Lindau associated renal cell carcinoma; clinicopathological long-term follow-up.

We evaluated the clinicopathological outcome of von Hippel-Lindau (VHL)-patients who had mainly undergone nephron sparing surgery (NSS) for renal cell carcinoma (RCC) when the tumour diameter has reached 4.0 cm. Multiple, bilateral RCC with high recurrence rates and subsequent repeated interventions, followed by increasing risk for end-stage renal failure and metastases is characteristic for VHL. NSS is widely used for VHL-associated RCC at 3.0 cm cut-off. 54 VHL patients underwent NSS, nephrectomy or thermal ablation for RCC. We analysed time to second treatment, overall and cancer specific survival, intra- and post-operative data as well as tumour characteristics. We also examined the effects of delaying removal of RCC to 4.0 cm cut-off. Median follow-up was 67 months. 54 patients underwent 97 kidney treatments. 96 % of first and 67 % of second interventions comprised of NSS. 0 % metastases were observed in the group with largest tumour size ≤4 cm. The probability for second surgery was 21 %, at 5 years and 42 % at 10 years. Median time to second NSS was 149.6 months. The overall and cancer specific survival rate was 96.5 and 100 % at 5-year follow-up, and 82.5 and 90.5 % respectively at 10-year follow-up. Median delay to second NSS at 4.0 cm cut-off versus 3.0 cm was 27.8 months. NSS was both successfully used in first and second surgery and to some extent even in third surgery. By following a strict surveillance protocol it is possible to support a 4.0 cm-threshold strategy for NSS, based on the assumption that delaying time to second NSS prevents patients from premature renal failure.

[Testosterone and psyche]. / Testosteron und Psyche.

Testosterone, like other steroid hormones, crosses the blood-brain barrier, and the androgen receptor is present in most parts of the human brain. Therefore, testosterone has many effects on the psyche, mainly in men but also in women. Most often discussed is its influence on sexuality, especially on desire and sexual fantasies, spontaneous nighttime erections, sexual activity, and the number of orgasms and ejaculations. Mood and energy are also testosterone related. Testosterone deficiency in male patients can lead to depressive disorders. In the past, elevated testosterone levels were seen as responsible for strongly aggressive behaviour. Some cognitive functions (spatial and mathematical sense, verbal skills) are, at least to a certain point, testosterone related. Due to the extremely complex functioning of the human brain, a scientifically exact statement regarding the true relationship between testosterone and human behaviour is not possible. On the one hand, the cause is definitively multifactorial, but on the other, testosterone is metabolised in the brain, and the metabolites act by themselves. Furthermore, a bidirectional relationship exists between hormones and human behaviour: Human behaviour is influenced by hormones, and human behaviour also has a direct influence on the levels of many hormones in the human body. Finally, much data in this field are derived from animal studies; studies on humans cannot be conducted because of ethical reasons or scientific and technical problems.

Interleukin-2/interferon-alpha2a/13-retinoic acid-based chemoimmunotherapy in advanced renal cell carcinoma: results of a prospectively randomised trial of the German Cooperative Renal Carcinoma Chemoimmunotherapy Group (DGCIN).

We performed a prospectively randomised clinical trial to compare the efficacy of four subcutaneous interleukin-2-(sc-IL-2) and sc interferon-alpha2a (sc-IFN-alpha2a)-based outpatient regimens in 379 patients with progressive metastatic renal cell carcinoma. Patients with lung metastases, an erythrocyte sedimentation rate < or =70 mm h(-1) and neutrophil counts < or =6000 microl(-1) (group I) were randomised to arm A: sc-IL-2, sc-IFN-alpha2a, peroral 13-cis-retinoic acid (po-13cRA) (n=78), or arm B: arm A plus inhaled-IL-2 (n=65). All others (group II) were randomised to arm C: arm A plus intravenous 5-fluorouracil (iv-5-FU) (n=116), or arm D: arm A plus po-Capecitabine (n=120). Median overall survival (OS) was 22 months (arm A; 3-year OS: 29.7%) and 18 months (arm B; 3-year OS: 29.2%) in group I, and 18 months (arm C; 3-year OS: 25.7%) and 16 months (arm D; 3-year OS: 32.6%) in group II. There were no statistically significant differences in OS, progression-free survival, and objective response between arms A and B, and between arms C and D, respectively. Given the known therapeutic efficacy of sc-IL-2/sc-INF-alpha2a/po-13cRA-based outpatient chemoimmunotherapies, our results did not establish survival advantages in favour of po-Capecitabine vs iv-5-FU, and in favour of short-term inhaled-IL-2 in patients with advanced renal cell carcinoma receiving systemic cytokines.

Ruptured inferior gluteal artery aneurysm with exsanguinating rectal hemorrhage controlled by transcatheter coil embolization.

A case of exsanguinating rectal and retroperitoneal hemorrhage resulting from a ruptured inferior gluteal artery aneurysm is presented. Transcatheter embolization of Gelfoam and a Gianturco coil device resulted in the control of bleeding and proved to be a life-saving measure in a patient who was a poor surgical candidate.

Ethanol-induced lipid peroxidation: potentiation by long-term alcohol feeding and attenuation by methionine.

Lipid peroxidation has been incriminated in some types of drug-induced liver injury, but it is unclear whether it contributes to or is present in alcoholic liver injury. In order to study this question, hepatic lipid peroxidation (measured as formation of diene conjugates) and hepatic GSH were assessed in baboons and rats after short- and long-term ethanol administration. Compared to controls, baboons fed alcohol for 1 to 4 years (chronic administration) had increased hepatic diene conjugates (16.9 +/- 4.8 OD/gm of liver) and depressed GSH (3.8 +/- 0.6 VS. 6.3 +/- 0.8 mumol/gm of liver; p less than 0.01) after an overnight withdrawal from ethanol. Administration of 1.6 gm/kg ethanol over 6 hr (acute administration) increased diene conjugates (17.6 +/- 4.3) and decreased GSH (3.2 +/- 0.5; p less than 0.01) in control animals and had an even greater effect in animals chronically fed alcohol (diene conjugates 48.5 +/- 9.2; GSH 1.8 +/- 0.3; p less than 0.001). In six rats fed alcohol for 5 to 6 weeks (chronic administration), an increase in diene conjugates was detected in microsomes (0.343 +/- 0.210 OD/mg of lipid) and mitochondria (0.143 +/- 0.061), accompanied by decrease in arachidonic acid and C22 polyenes, after acute ethanol administration (3 gm/kg p.o.) but no significant change in GSH. Simultaneous administration of methionine attenuated diene conjugate formation (0.107 +/- 0.058 and 0.035 +/- 0.020 OD/mg of lipid, respectively) and fatty acid changes. Thus chronic alcohol feeding potentiates lipid peroxidation produced by an acute dose of ethanol; these changes are not dependent on GSH depression but may be potentiated by it.

Comparison of the activation status of tumor infiltrating and peripheral lymphocytes of patients with adenocarcinomas and benign hyperplasia of the prostate.

BACKGROUND: The presence of lymphocytic infiltration in prostate carcinomas has been shown to have prognostic relevance. However, it is not yet clear if this infiltrate represents a tumor-specific activated cell population or not. Therefore, the aim of the present study was to characterize the activation status of freshly isolated tumor infiltrating lymphocytes (TIL) from prostate carcinomas (PCa) and benign hyperplasia (BPH) with respect to the mRNA expression of cytokines and apoptotic factors. METHODS: TIL were isolated from mechanically disaggregated tumor material by gradient centrifugation. The cells of the interphase were depleted from epithelial cells with anti-human epithelial antigen magnetic beads and then CD3(+)- lymphocytes were selected with magnetic beads against this determinant. In these pure lymphocyte preparations the mRNA expression of IL-1, IL-10, IFN-gamma, TNF-alpha, Fas and Fas ligand was determined by using a semiquantitative RT-PCR. Contamination with tumor cells was excluded by a PCR for PSA and PSMA. RESULTS: The CD3(+)-TIL from 21 patients with PCa and 20 patients with BPH expressed significantly higher levels of IL-10- and Fas ligand-mRNA compared to the autologous CD3(+)- PBL, whereas the expression of IL-1-, TNF-alpha- and Fas-mRNA was not different in either cell population. In contrast, the mRNA levels of IFN-gamma were significantly higher only in the CD3(+)-TIL from the carcinomas but not from the BPH compared to autologous CD3(+)-PBL. CONCLUSIONS: Since high levels of IFN-gamma have been reported to be produced by specifically lytic lymphocytes, our results suggest the presence of specifically activated TIL in the prostate carcinomas but not in the BPH, whereas inflammatory activated TIL are present both in the carcinomas and the BPH.

Metaplasia intestinal especializada de esôfago distal na doença do refluxo gastroesofágico: prevalência e aspectos clínico-epidemiológicos / Specialized intestinal metaplasia of distal esophagus in the gastroesophageal reflux disease: prevalence and clinical-demographic features

RACIONAL: A metaplasia intestinal especializada pode ser classificada, de acordo com os achados endoscópicos e histológicos, em Barrett longo, Barrett curto e metaplasia intestinal da cárdia. O esôfago de Barrett é doença adquirida que ocorre em aproximadamente 10 por cento a 13 por cento dos indivíduos com doença do refluxo gastroesofágico e representa uma condição pré-neoplásica. É caracterizado por substituição do epitélio escamoso estratificado pelo metaplásico colunar especializado, contendo células caliciformes. OBJETIVOS: Determinar, prospectivamente, a prevalência e as características clínico-epidemiológicas da metaplasia intestinal especializada de esôfago distal na doença do refluxo gastroesofágico. MÉTODOS: Entre abril e outubro de 2002, 402 pacientes com sintomas da doença do refluxo gastroesofágico foram avaliados através de questionário padronizado que abordava as variáveis demográficas e foram submetidos a exame endoscópico com biopsias 1 cm abaixo da junção escamocolunar, nos quatro quadrantes. RESULTADOS: Metaplasia intestinal especializada foi encontrada em 18,4 por cento dos pacientes: 0,5 por cento Barrett longo, 3,2 por cento Barrett curto e 14,7 por cento metaplasia intestinal da cárdia. Houve tendência de maior número de homens apresentando esôfago de Barrett e mulheres com metaplasia intestinal da cárdia. Todos com esôfago de Barrett eram da raça branca. Não houve relação entre a intensidade dos sintomas da doença do refluxo gastroesofágico e a presença de metaplasia intestinal especializada. O tempo de duração de sintomas superior a 5 anos foi uma tendência nos portadores de esôfago de Barrett. Este grupo também apresentou mais hérnia de hiato e esofagite mais intensa do que aqueles com metaplasia intestinal da cárdia. Não houve relação entre uso de tabaco ou álcool e metaplasia intestinal especializada. CONCLUSÕES: Esôfago de Barrett foi mais relacionado ao sexo masculino, com sintomas de longa cronicidade, esofagite mais intensa e sem associação com tabaco ou álcool.

Derrame pericárdico com tamponamento cardíaco como forma de apresentaçäo de hipotireoidismo primário / Pericardial Effusion with Cardiac Tamponade as a Form of Presentation of Primary Hypothyroidism

The authors describe a case of pericardial effusion accompanied by cardiac tamponade caused by primary hypothyroidism. Diagnosis was made by exclusion, because other causes of cardiac tamponade are more frequent. Emergency treatment of cardiac tamponade is pericardiocentesis (with possible pericardial window), and, after stabilization, performance of hormonal reposition therapy with L-thyroxin