Probability to retrieve testicular spermatozoa in azoospermic patients.

AIM: The degree of probability to retrieve spermatozoa from testicular tissue for intracytoplasmic sperm injection into oocytes is of interest for counselling of infertility patients. We investigated the relation of sperm retrieval to clinical data and histological pattern in testicular biopsies from azoospermic patients. METHODS: In 264 testicular biopsies from 142 azoospermic patients, the testicular tissue was shredded to separate the spermatozoa, histological semi-thin sections of which were then evaluated using Johnsen score. RESULTS: The retrieval of spermatozoa correlated significantly ( P < 0.001) with the testicular volume ( r = 0.49), the FSH concentration ( r = -0.66), the maximum score (r = 0.85) and the mean Johnsen score (r = 0.81). In the multivariate regression analysis the successful testicular sperm extraction showed the closest relationship to the maximum score. The testicular volume correlated significantly with the mean Johnsen score ( r = 0. 64, P < 0. 001), and the basal serum FSH concentration mainly with the maximum score ( r = - 0.77; P < 0.001). Patients with a history cryptorchidism showed a significantly lower Johnsen score compared to the patients who did not have any testicular disease in the past (3.7 +/- 2.4 vs. 5.9 +/- 2.5; P < 0. 01). CONCLUSION: In a limited range, the testicular volume and the FSH concentration in serum were related to the Johnsen score which correlated significantly with the sperm retrieval. The successful sperm retrieval can be expected in all azoospermic patients irrespective of the results of clinical examination. However, the probability of retrieval of spermatozoa decreased significantly in patients with a FSH level > 18 U/L, testicular volume < 5 mL, mean Johnsen score <5, and maximum Johnsen score <7.

[Spiral CT vesiculography--a new examination technique in patients with histologically verified prostate carcinoma]. / Die Spiral-CT-Vesikulographie--Eine neue Untersuchungstechnik bei Patienten mit histologisch gesichertem Prostata-Karzinom.

PURPOSE: Development of an imaging method for detection of seminal vesicle invasion in patients with histologically proven carcinoma of the prostate. MATERIALS AND METHODS: In 24 patients with histologically proven carcinoma of the prostate we preoperatively performed an antegrade vaso-vesiculography with non-ionic, iodine-containing contrast agent followed by a spiral CT of the seminal vesicles. RESULTS: In 21 patients we achieved both a bilateral and a bulging enhancement of the seminal vesicle lumen. The method is introduced and described in detail. CONCLUSIONS: Intraductal application of contrast agent just before spiral CT results in unfold and bulging enhanced seminal vesicles. From the differentiation of the lumen, the wall, and the surrounding fat of the seminal vesicles as well as the enhanced ejaculatory ducts we expect information on tumorous infiltration in cases of histologically proven carcinomas of the prostate.

[Anatomic principles of urinary incontinence]. / Anatomische Grundlagen der Harnkontinenz.

The morphological fundamentals of urinary continence are still subject to controversy. This was the reason for a renewed examination of the sphincter musculature of the lower urinary tract. This study included 50 male and 15 female autopsy specimens. The organs of the lower urinary tract including the neighboring organs had been removed in their entirety and histologically reprocessed en bloc as a complete series of sections. We were able to demonstrate that the internal sphincter or m. sphincter vesicae is represented as a circular, distinct structure which elliptically embraces the internal urethral orifice. Lamellas of the detrusor are not involved in the formation of the internal sphincter. In females and males, the external sphincter consists of a striated and a smooth muscular part (m. sphincter urethrae transversostriatus et glaber). In transverse sections, the muscle has a horseshoe shape. It is completely separated by connective tissue from the musculature of the pelvic floor. A deep transverse perineal muscle does not exist. The histological findings were used for the construction of a digital three-dimensional model of the anatomy of the lower urinary tract. Computer animations of the model with integrated original histologies were generated and stored as a computer video on a CD-ROM attached to this journal.

[Endoscopic extraperitoneal radical prostatectomy. Results after 300 procedures]. / Die endoskopische extraperitoneale radikale Prostatektomie (EERPE). Ergebnisse nach 300 Eingriffen.

During the last decade laparoscopy has become the standard technique in the urologist's armamentarium due to constant technological advancements and refinements. Laparoscopic radical prostatectomy (LRPE), although technically demanding and associated with a considerable learning curve, has become the operative procedure of choice for patients with clinically localized prostate cancer in selected and specialized urologic centers around the globe. However, a major drawback of LRPE is the transperitoneal route of access to the extraperitoneal organ of the prostate. The principal disadvantages of LRPE are potential intraperitoneal complications. Endoscopic extraperitoneal radical prostatectomy (EERPE) is a further advancement of minimally invasive surgery as it overcomes the limitations of LRPE by the strictly extraperitoneal route of access. Based on our growing experience with this procedure we introduce several technical modifications, improvements, and refinements including a nerve-sparing, potency-preserving approach (nEERPE) in an effort to further improve this minimally invasive procedure. We report our short-term follow-up results after 300 procedures. The mean operative times were 115 min without and 150 min with lymph node dissection, in total 140 min (range: 60-260 min). There was no conversion and the transfusion rate was 1.3%. There were three early reinterventions (two bleeding and one hematoma) and five late reinterventions (four symptomatic lymphoceles and one colostomy due to a rectal fistula). Pathological stage was pT2a in 54 patients (18%), pT2b in 87 patients (29%), pT3a in 115 patients (38.3%), pT3b in 40 patients (13.3%), and pT4 in 4 patients (1.3%). Positive surgical margins were found in 9.2% (13/141) of patients with pT2 tumor and 30.3% (47/155) of patients with pT3 tumor. The mean catheterization time was 6.9 days. Six and twelve months postoperatively 86.3 and 89.6% of the patients were completely continent; 9.2% of patients needed 1-2 pads per day and 4.5 and 1.2% of patients needed more than 2 pads per day, respectively. Short-term oncological and functional results of EERPE are at least as favorable as in LRPE while operative times are shorter and complication rates are low. EERPE is a technical advancement because it combines the advantages of a totally extraperitoneal access with the advantages of a minimally invasive procedure.

[The elderly patient with urge incontinence or urge-stress incontinence - efficacy and cardiac safety of propiverine]. / Der ältere Patient mit Drang-Symptomatik bzw. kombinierter Drang/Stress-Inkontinenz-Wirksamkeit und kardiale Sicherheit von Propiverin.

PURPOSE: The efficacy of propiverine in elderly patients suffering from urge incontinence or urge-stress incontinence was intended to be investigated. Especially in elderly patients a cardiac influence of propiverine is possible due to its dual mode of action. That is why besides the efficacy especially the cardiac safety was intended to be investigated. MATERIAL AND METHODS: Ninety-eight patients (21 male, 77 female; 67.7 +/- 6.3 years of age) suffering from urgency, urge incontinence or mixed urge-stress incontinence were included in the double-blind, multicentre, placebo-controlled, randomized study. After a two-week placebo run-in period, the patients received propiverine (15 mg t. i. d.) or placebo (t. i. d.) for four weeks. Before (U 1, U 2) and during the treatment period (U 3, U 4), standard ECG's and 24 h long-term ECG's were recorded. RESULTS: Propiverine caused a significant reduction in the micturition frequency (U 2 : 8.7 +/- 4.2, U 4 : 6.5 +/- 3.2 ml; p < 0.01) reflected in a significant increase in the average micturition volume (U 2 : 163.5 +/- 65.9, U 4 : 216.3 +/- 101.5 ml; p < 0.01) and a significant reduction in the episodes of incontinence (- 54 %; p < or = 0.05). These findings were confirmed by the overall assessment after four weeks in which approximately 90 % of patients under propiverine were either free from urge incontinence and urge symptoms or improved. The efficacy parameters demonstrated a better efficacy for urge incontinence than for mixed urge-stress incontinence. Resting and ambulatory electrocardiograms evidenced no significant changes. Neither QTc interval nor other cardiac parameters were relevantly altered. The frequency of cardiac events (Lown classes IV a/b) was fortuitous, revealing no difference between placebo and propiverine. The incidence of adverse events was very low (2 % dryness of the mouth under propiverine) and confirmed by the findings from the quality of life questionnaires. CONCLUSIONS: A favourable benefit-risk ratio in the treatment of elderly patients suffering from urgency, urge incontinence or combined urge-stress incontinence is therefore proven for propiverine. Cardiac arrhythmia were not induced.

[Urinary continence in the female--aspects of function]. / Die Harnkontinenz der Frau--Aspekte zur Funktion.

The physiology of continence was studied in 33 continent and 62 incontinent females, respectively, under morphological aspects. Only 60 percent of the urethral length were found to ensure full close patency. This region is represented by a circular musculatory sphincter system. It was found that stress situations may cause changes in the sphincteric function along with a rise in the abdominal pressure. Urethral closure patency was found to be disturbed even at a resting state. The changes which were observed in the resting continence have been manifested themselves as a shortening of the closing proximal urethra "in itself" and a corresponding shortening of the absolute anatomical urethral length by the same proportion. The anatomical urethral length in females is therefore of clinical significance in the diagnostical screening for urinary incontinence.

[Urinary continence in the female--a morphologic study]. / Die Harnkontinenz der Frau--eine morphologische Studie.

Physiological studies which can be traced back into the last century have produced a large number of theories on continence and micturition. A literature review may cause some doubts on the clinical applicability of these theories. Not considering the disagreement on the morphology of the lower urinary tract, many questions like the functional interpretation of morphological findings remain unanswered. A renewed morphological study of the urinary bladder neck and its adjacent structures in males and females were done. The histological examination of 30,000 serial sections have revealed a widely different morphological structure in comparison with the literature. Additional muscular systems were identified, new defined and their possible function was discussed.

[Significance of immunosuppression for tumor growth and tumor propagation in an allogeneic study]. / Die Bedeutung der Immunsuppression für Tumorwachstum und Tumorausbreitung im allogenen Experiment.

Summarizing we can establish that by an adequate intensive immunosuppression the successful performance of a tumour transplantation, even of a heterologous one, is possible. However, the tolerance of the heterologous tumour remains only for as long as there exists an immunosuppression. The following rejection is unequivical at the typical morphological picture. These finding should remind of the possible effects of the immunosuppression in the syngenic system, particularly in the tumour patients, and also of the fact that all immunosupressively acting measures in this group of patients must undergo a strong criticizm.

A new theory of micturition and urinary continence based on histomorphological studies. 3. The two parts of the musculus sphincter urethrae: physiological importance for continence in rest and stress.

The urethral component of continence is the object of a lively discussion. A large number of the examiners interpret the external striated urethral muscle as part of the muscular pelvic diaphragm, formed partially or completely by the so-called musculus transversus perinei profundus. About 30,000 histological sections have been examined by light microscopy in a systematical manner. In contrast to numerous suggestions in the literature the musculus sphincter urethrae has been found to be an independent morphological unit in our investigation. It is separated from the surroundings by a segment of connective tissue. Furthermore, with the help of transversal, sagittal and frontal serial sections it was possible to show that the musculus transversus perinei profundus does not exist. In the female as well as in the male in the direction of the urethra the outer sphincter always borders on a layer of smooth muscle cells. In order to distinguish both parts the terms musculus sphincter urethrae transversostriatus and musculus sphincter urethrae glaber are introduced. In the context of a new continence theory three structures capable of occluding the urinary bladder will be discussed. It should be emphasized that the musculus sphincter urethrae glaber makes long-term continence possible.

A new theory of micturition and urinary continence based on histomorphological studies. 5. The musculus ejaculatorius: a newly described structure responsible for seminal emission and ejaculation.

Theories of seminal emission and ejaculation based on morphology especially of the dorsal longitudinal urethral muscle system are found very infrequently in the literature. Our own examinations carried out on serial sections of the whole distal urethral complex taken from 50 male and 15 female autopsy preparations prove that the dorsal longitudinal urethral muscle system represents an independent smooth muscle. In the female, the muscle system runs outside the sphincter system. In the male, it is the direct continuation of the musculature of the ejaculatory ducts and its expansion is generally restricted to the urethra below the colliculus seminalis. Within the urethra the urethral crest is protruded. Differences in the degree of the formation of the muscle in various age groups will be described. For this newly described muscle structure, we suggest the term musculus ejaculatorius as, due to purely anatomic reasons, an involvement in the process of ejaculation seems to be conclusive. A theory of seminal emission and ejaculation is given as a mass action of the musculature of the bladder neck.

[Urodynamic measurements of the lower urinary tract--technical realization and implications for the interpretation of findings]. / Die urodynamische Messung am unteren Harntrakt--technische Realisierung und Konsequenzen für die Befundinterpretation.

technique of urodynamic measurement is presented which allows both screening and complex measurements to be carried out by a choice of variably combinable individual parameters, exclusively on the basis of GDR instruments and taking into account the unity of the basic functions: collection of urine, miction and continence. Ways in which the readings can be influenced by the methods used are pointed out. A standardized course of examination for complex urodynamic measurement is presented.

A new theory of micturition and urinary continence based on histomorphological studies. 4. The musculus dilator urethrae: force of micturition.

In an anatomical study of serial sections of the bladder neck taken from 65 cadavers of all age groups the ventral longitudinal muscle system is shown as a single unit. It is characterized by two origins and two insertions. A detailed description is given. It should be emphasized that there is no connection between this muscle system and any muscle layer of the urinary bladder. The muscle bundles of the upper part of the ventral longitudinal urethral muscle system cross in stages the whole ventral circumference of the trigonal sphincter muscle with functional consequences. The lower part is closely combined with the lumen of the urethra. During contraction the muscle could be able to open the musculus sphincter trigonalis and the musculus sphincter urethrae; we called them musculus dilator urethra. Summarizing all presented histomorphological results of parts 1-4 of these papers [Dorschner et al.; Urol Int 52;1994] a new theory of micturition and its initiation is presented.

A new theory of micturition and urinary continence based on histomorphological studies. 2. The musculus sphincter vesicae: continence or sexual function?

Results of a histomorphological study of serial sections carried out in frontal, transversal and sagittal directions in 65 bladder necks are presented. It is shown that the trigonal system of the urinary bladder consists of two anatomical structures: first, of a muscle originating from the muscle system of both ureters and converging to form within the bladder the interureteric ridge, the musculus interuretericus and of a second structure forming the actual trigonum vesicae. It is the musculus sphincter trigonalis or musculus sphincter vesicae. This muscle elliptically embraces the internal urethral orifice and is only formed by one muscle lamella. It does not as has often been described extend in any form to the urethra or to the surroundings. The so-called Bell muscle does not exist. During the reproductive years the lower part of the sphincter trigonalis is strongly pervaded with prostate tissue. This could enable the muscle to have a double function: a continence function in accordance with a consequent distinction between the urinary bladder and the urethra as urinary and sexual tract, and during ejaculation the muscle could prevent the retrograde ejaculation and on the other hand the contraction of the muscle could lead to the release of the prostate secretion.

[Effect of Mictonorm (propiverin hydrochloride) on the female urethra]. / Zur Wirkung von Mictonorm (Propiverinhydrochlorid) auf die weibliche Urethra.

In a study about drug-induced changes of the urodynamics of the female urethra by Mictonorm 14 women with urge-symptoms were investigated. According to a special examination plan the control of Mictonorm-effect was realized with the analysis of the parameters of the urethra pressure profile at rest and under stress conditions and of the vesico-urethral pressure transmission. The result shows that there were no significant changes of the urodynamics of the female urethra, therefore one can accept selective detrusor effects by oral application.

[Urodynamic studies on normal bladders and bladders in metabolic disorders using diabetes mellitus as an example]. / Urodynamische Untersuchungen an der gesunden und stoffwechselgestörten Harnblase am Beispiel des Diabetes mellitus.

In various diseases of the kidney and the urinary bladder, in disturbances of potency and diseases of the outer genital the diabetes mellitus play an essential role. It was the aim the present investigations to establish with the help of manometric examinations of the urinary bladder in diabetics as well as in a comparative group which had no disturbed metabolism in what extent there exist objectively provable differences of the parameters chosen by us. From the results is to be stated that in diabetics, despite a slight increase of the capacity of the urinary bladder, a significant increase of the sphincter opening pressure and of the voluntary tonus of the sphincter is present. We explain these changes as an expression of a beginning disturbance of the innervation of the urinary bladder. In males of this age group from this result disturbances of miction which may lead to incorrect judgments, particularly in connection with a prostatic adenoma.

The dispute about the external sphincter and the urogenital diaphragm.

PURPOSE: Basic scientific facts, such as anatomical structures, are rarely subjected to critical reappraisal. Nevertheless, several clinical phenomena exist which are inconsistent with the description of the anatomy of the so-called external sphincter muscle and urogenital diaphragm. MATERIALS AND METHODS: We performed a global examination of the anatomy of the entire lower urinary tract in 50 male autopsy specimens. For comparison magnetic resonance imaging of the same regions was performed on 12 healthy patients. RESULTS: Direct comparison of the results of both methods revealed the exact same topography of the bladder neck. The external sphincter or musculus sphincter urethrae is an independent morphological unit separated from the surrounding pelvic floor muscles by connective tissue. CONCLUSIONS: The musculus transversus perinei profundus or deep transverse perineal muscle, which is believed to constitute the major element of the urogenital diaphragm, does not exist. There is histomorphological evidence that the external sphincter consists of a striated (musculus sphincter urethrae transversostriatus) and smooth muscle (musculus sphincter urethrae glaber) component.

Comparative anatomy of the male guinea-pig and human lower urinary tract: histomorphology and three-dimensional reconstruction.

The guinea-pig is often used for experimental studies in urology. However, the anatomy of the lower urinary tract of the guinea-pig is poorly described in the literature. The structure and function of the lower urinary tract, i.e. continence, micturition and sexual function, are closely related to the gross anatomy of the pelvis and the fine structure of the musculature. We investigated the anatomy and histomorphology of the lower urinary tract by serial sections in male guinea-pigs and compared it to that in humans. Immunohistochemical stainings for alpha-smooth muscle cell actin were used to differentiate between smooth and striated muscles. By using whole pelvic preparations, including all internal organs preserved in their in situ location for three-dimensional reconstruction, we developed three-dimensional models, which elucidate the spatial relationship of all muscular structures and can help to deduce functional aspects of lower urinary tract function. In the guinea-pig, most of the muscles found in humans can be demonstrated in comparable location and extension. However, the structure of the prostate and the existence of the so-called coagulation glands define a significant difference in the morphology of the prostatic urethra.

A new theory of micturition and urinary continence based on histomorphological studies. 1. The musculus detrusor vesicae: occlusive function or support of micturition?

Micturition and urinary continence theories have been under discussion since the last century. Up to now all these theories have been unsatisfactory. There is an obvious discrepance between the anatomical presentation and the clinical perceptions and physiological phenomena. This was the reason for a renewed and global examination of the whole distal urinary tract. The results are published in five successive papers. Our own examinations are based on 30,000 serial sections of the bladder neck taken from 65 male and female cadavers of all age groups. The muscle system of the urinary bladder consists of a network of smooth muscle cells forming three layers. Caudally the longitudinal muscle layers form two special recently described structures: the collare vesicae and nodus vesicae. None of the muscle systems of the urinary bladder leaves the spatial dimension of the organ. Simply two anatomical structures fix the urinary bladder in the pelvis. Dorsally it is the musculus vesicoprostaticus and the musculus vesicovaginalis, respectively; ventrally the existence of the musculi pubovesicales is introduced. There is no involvement of the lamellas of the bladder muscles in the formation of the urinary sphincter. Therefore the morphological substrate for a hitherto generally acknowledge contribution of the detrusor vesicae to the active continence function does not exist.

Comparative anatomy of the male guinea-pig and human lower urinary tract: histomorphology and three-dimensional reconstruction.

The guinea-pig is often used for experimental studies in urology. However, the anatomy of the lower urinary tract of the guinea-pig is poorly described in the literature. The structure and function of the lower urinary tract, i.e. continence, micturition and sexual function, are closely related to the gross anatomy of the pelvis and the fine structure of the musculature. We investigated the anatomy and histomorphology of the lower urinary tract by serial sections in male guinea-pigs and compared it to that in humans. Immunohistochemical stainings for alpha-smooth muscle cell actin were used to differentiate between smooth and striated muscles. By using whole pelvic preparations, including all internal organs preserved in their in situ location for three-dimensional reconstruction, we developed three-dimensional models, which elucidate the spatial relationship of all muscular structures and can help to deduce functional aspects of lower urinary tract function. In the guinea-pig, most of the muscles found in humans can be demonstrated in comparable location and extension. However, the structure of the prostate and the existence of the so-called coagulation glands define a significant difference in the morphology of the prostatic urethra.