Psychological distress and adjustment to disease in patients before and after radical prostatectomy. Results of a prospective multi-centre study.

The aim of this prospective multi-centre study was to evaluate the level of psychological distress (PD) and adjustment to disease in patients who underwent radical prostatectomy. Furthermore, the impact of urinary incontinence and erectile dysfunction on PD was assessed. Anxiety, depression and PD were evaluated using the Hospital Anxiety and Depression Scale in 329 prostate cancer patients before surgery as well as 3, 6 and 12 months after surgery. These results were compared with those of a male German general population reference group. Adjustment to disease was assessed using the Perceived Adjustment to Chronic Illness Scale. Patients reported low levels of PD at all points of assessment similar to population norms of age-matched German men. Persistent PD was seen in about 8% of the patients and 20% had PD at least two of the measurement points. Relevant predictors for PD after surgery were urinary symptoms and baseline PD. Adjustment to disease was highest before surgery and had significantly reduced at 3 and 6 months after surgery. In general, men are resilient to the experience of localised prostate cancer and adjust well psychologically after surgery. However, between 8% and 20% of patients could possibly benefit from mental health support.

[Modern nephrolithiasis in the complex setting of metaphylaxis : Latest epidemiological data and a nationwide survey in private practices]. / Die Nephrolithiasis im komplexen Metaphylaxesystem heute : Epidemiologische Daten zur Prävalenz und Resultate einer deutschlandweiten Praxisumfrage.

The focus of this work is on aspects of the current management of recurrent nephrolithiasis in private practices and outpatient departments in Germany. We wanted to make a contribution to the epidemiological discourse as well as for an instrument for the self-reflection and complex classification of urolithiasis in everyday practice by a first-time determination of population-based, age- and gender-based data based on the full recording of urological diagnoses and treatments in the federal accounting setting. The analysis of the taken positions in this representative practice survey prove to some extent information and experience deficits in the handling of complicated nephrolithiasis. Therefor more than 90% of the interviewees demand a structured practical training initiative. In this context, nearly 65% of practices also support the establishment of regional consultation hours. A majority strongly welcomes the establishment of a National Register of Urolithiasis, but nearly 40% are skeptical about defining pending framework conditions.

[Urolithiasis in children--rational diagnosis, therapy, and metaphylaxis]. / Urolithiasis bei Kindern--rationelle Diagnostik, Therapie und Metaphylaxe.

With a proportion of 1-5%, children constitute only a small number of all patients with urolithiasis. Nevertheless, pediatric stone disease is an important health care problem because of the high recurrence rate and the threat of progredient renal function impairment with consecutive loss of quality of life. Modern therapies, especially extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL), have caused a revolution in the operative treatment spectrum. Open surgery is required for stone removal only rarely, such as for the simultaneous repair of urinary tract anomalies. The minimally invasive modalities of modern stone therapy - mainly ESWL as the treatment of first choice - have led to widespread disregard of stone metaphylaxis. The important principle that says an urinary stone is just a symptom and not the cause of the disease is often forgotten. So it must be noted that despite the high standard of care in Germany, not all problems regarding urinary stone disease are being resolved, particularly in childhood. This article presents the current knowledge of the most important aspects of stone therapy and the methods of treatment in children.

Comparison of different methods of treating varicocele.

Varicocele treatment was performed in 331 patients. One hundred fifteen patients were operated upon according to the technique of Bernardi (1947), 80 patients underwent occlusion of the testicular vein by detachable balloons, 47 patients were treated with percutaneous sclerotherapy, and 89 patients underwent laparoscopic varicocele treatment. The laparoscopic occlusion of the testicular vessels was done in two different ways: (1) coagulation of the testicular veins with electrocoagulating tweezers, and (2) occlusion of the suprainguinal testicular vessel with metal clips and transection of the vessels. Laparoscopic Group 1 showed a clearly higher complication rate and recurrence rate in comparison with the other methods, whereas in Group 2 we observed the best results with only 4% complications and recurrences. Because of its higher complication rate and recurrence rate, laparoscopic electrocoagulation of the testicular veins proved to be inadequate.

[MRT in nonpalpable testes]. / MRT bei nichttastbaren Hoden.

Magnetic resonance imaging was performed in 22 male patients for localisation of 27 nonpalpable undescended testes. The operative verification, carried out in 19 testes (15 patients) served as basis for checking on the accuracy of MRI results and for their comparison with those of sonography and laparoscopy. The impalpable testis was localised via MRI in 13 cases and its lack was correctly established in three cases. There were three false MRI diagnoses. The suspicion of two intraabdominal localised testes were not confirmed at surgery and one intracanalicular testes were not seen by MRI. The low signal intensity of the undescended testes on T2-weighted images is indicative for fibrotic changes and may be of value for more accurate planning of the operative volume. MRI offers a new promising opportunity for localisation and morphologic estimation of the undescended testis and should be performed before the invasive investigation methods.

Microsurgical technique and results of testicular autotransplantation in children--essential venous anastomosis.

For more than 10 years autotransplantation of the testis has proved to be a surgical technique with a definitive place in the therapy of high-abdominal cryptorchidism. It is a procedure to be employed in situations where appropriate mobilization yields an ineffective orchiopexy. In a review of 245 cases in the literature a success rate of 87% is reported. The problems of diagnostic procedures like ultrasonography, magnetic resonance imaging and laparoscopy and of operative technique are described in detail. The relevance of venous anastomosis is discussed and stressed, and the results of 8 own cases are presented.

[Laparoscopic diagnosis and therapy of cryptorchism]. / Laparoskopische Diagnostik und Therapie beim Kryoptorchismus.

Between May 1987 and December 1991, laparoscopy was performed in 33 selected children with 40 nonpalpable testes, to localize the testes. Of 40 testes sought, 16 were present (14 intra-abdominal and 2 inguinal), and in 24 cases testicular aplasia was verified. The authors describe the technique of laparoscopy for unilateral and bilateral undescended testes. Exact anatomical localization of the testes by laparoscopy facilitated accurate planning of operative repair. The advantages of laparoscopy compared with ultrasound and MR imaging in 14 selected patients are described. In 3 patients with an intra-abdominal hypoplastic testis we performed laparoscopic orchiectomy. This new operative procedure is described. Laparoscopic orchiectomy is minimally invasive, offering a practicable alternative to orchiectomy in the case of an atrophic or hypoplastic abdominal testis. No complications were noted.

[Experiences with laparoscopic lymphocele drainage]. / Erfahrungen mit der laparoskopischen Lymphozelendrainage.

Lymphoceles are among the most frequent surgical complications of pelvic surgery. In ten patients with large lymphoceles in the pelvis after successful kidney transplantation or radical suprapubic prostatectomy we performed laparoscopic drainage of the lymphocele. Laparoscopic windowing of lymphoceles is a safe, minimally invasive form of treatment and a successful alternative to open surgical marsupialization, percutaneous puncture or external drainage of the lymphocele.

[Complications of laparoscopic interventions in urology]. / Komplikationen laparoskopischer Eingriffe in der Urologie.

From April 1987 to November 1995, we performed 741 laparoscopic procedures, in which we observed 14 major complications (1.9% complication rate). The complication rate was 4% in the first 100 procedures--more than twice as many as in the following 631 procedures, which had a complication rate of 1.6%. Although between 1987 and 1990 laparoscopy was mainly used for the diagnosis of cryptorchidism, we then progressed to therapeutic measures with the help of the laparoscopic technique. After performing laparoscopic orchiectomy (1990), we introduced fenestration of lymphoceles (1991), varicocelectomy (1991), pelvic staging lymphadenectomy (1992), nephrectomy (1992), and adrenalectomy (1994) into clinical practice, in addition to other, more rarely occurring procedures. The complications we observed demonstrate a clear learning curve and show that critical, gradual practice of the laparoscopic technique is necessary.

Erectile dysfunction after radical prostatectomy: the impact of nerve-sparing status and surgical approach.

The core question of the study was whether the nerve-sparing status and surgical approach affected the patients' sexual life in the first year after surgery. In addition, determinants of erectile function (EF) and the extent of sexual activity were investigated. We conducted a multicentric, longitudinal study in seven German hospitals before, 3, 6 and 12 months after radical prostatectomy (RP). A total of 329 patients were asked to self-assess the symptoms associated with erectile dysfunction (ED). These symptoms were assessed using the International Index of Erectile Function and EORTC QLQ-PR25 questionnaires. A multiple regression model was used to test the influence of clinical, socio-demographic and quality-of-life-associated variables on the patients' EF 1 year after RP. Before surgery, 39% of patients had a severe ED (complete impotence). At 3, 6 and 12 months after surgery, it was 80, 79 and 71%, respectively. Although the surgical approach had no significant effect on EF, patients who had undergone nerve-sparing surgery had significantly lower ED rates. Nevertheless, 1 year after RP, 66% of these patients had severe ED. Age, nerve-sparing status and the burden of urinary symptoms had the greatest impact on the patients' EF. Regardless of nerve-sparing status and surgical approach, postsurgical improvement of EF does not mean a full convalescence of presurgical EF. Instead, it may rather reduce the degree of postsurgical ED in time. Consequently, urologists should disclose to the patient that ED is a likely side effect of RP.

[Clinical experience in the diagnosis and treatment of kidney trauma]. / Klinische Erfahrungen mit Diagnostik und Therapie von Nierentraumen.

BACKGROUND: Kidney trauma belongs to the rarely arising urological illnesses. In recent years guidelines for the treatment of urological injuries have been compiled by the Société Internationale d'Urologie (SIU) and the European Association of Urology (EAU). In the current literature increasingly more meaning is granted to a conservative in relation to a surgical therapy procedure, also with grade 4 and 5 kidney injuries. PATIENTS: From 2002 to 2009, 83 patients with kidney injuries were treated in our hospital. There were 56 patients with grade 1 and grade 2 injuries, 12 patients with grade 3 and grade 4 injuries, and in addition, a total of 15 patients with a grade 5 injury. RESULTS: In 75% of the cases a conservative procedure could be arranged depending on the further clinical course. In 25% of the cases, however, relative and/or absolute indications for operative intervention stood in the foreground, so that this group had an exploratory laparotomy. In 7 cases total nephrectomy had to be performed; however, in 11 cases organ-preserving surgery was possible.

How far is the preoperative Kattan nomogram applicable for the prediction of recurrence after prostatectomy in patients presenting with PSA levels of more than 20 ng/ml? A validation study.

OBJECTIVE: We present an external validation study investigating the applicability of the preoperative Kattan nomogram for predicting recurrence after prostatectomy in a population of patients with serum prostate-specific antigen (PSA) levels exceeding 20 ng/ml. MATERIALS: In the evaluation of clinical parameters pooled from a total of 191 patients presenting with PSA levels ranging between 20.1 and 100 ng/ml, the PSA-free survival rate 60 months after surgery was calculated according to Kattan nomograms. Subsequently, the results were statistically compared with the corresponding actual survival rates obtained from Kaplan-Meier analysis. For this purpose, the patients were assigned to one of four different risk groups according to predictions derived from the Kattan nomograms, enabling a direct comparison of expected (as predicted by Kattan nomogram) versus actual survival of each patient investigated in our study. RESULTS: Predicted PSA-free survival rates were determined to be as follows: 83% (low risk group); 66% (intermediate risk group); 39% (intermediate-high risk group), and 10% (high risk group) in comparison with the actual survival rates determined to be 63, 62, 40 and 21%, respectively. For PSA levels ranging between 20.1 and 30 ng/ml, 30.1 and 50 ng/ml, and 50.1 and 100 ng/dl, PSA-free survival rates were found to be 57, 37, and 27% (p=0.0017), respectively, during a 5-year post-prostatectomy follow-up. CONCLUSIONS: The Kattan nomogram shows good statistical concordance with actual survival rates in the mean risk quadrants, but considerable differences were demonstrated concerning individuals with either a high or with a low risk of cancer progression.

[Clinical testis transplantation. Review of indications, surgical technic and results of auto-, allo- and isotransplantation]. / Klinische Hodentransplantation. Ubersicht zu Indikationsstellung, Operationstechnik und Ergebnissen bei der Auto-, Allo- und Isotransplantation.

Human testicular transplantation using microsurgical technique is gaining popularity. Since 10 years autotransplantation of the testis proved to be a surgical technique with a definitive place in the therapy of high abdominal cryptorchidism. It is a procedure to be employed in situations where appropriate mobilisation yields an ineffective orchidopexy. In a review of 130 cases in the literature a success rate of 87% is reported. The problems of diagnostic procedures, of the indication and the possibilities of ischemia protection are described. Iso- and allotransplantation of the human testis are reported from few centers, but the results are excellent. Therefore, the operative technique and the long-term results are described in detail.

[Maldescensus testis and testicular tumors. Personal experiences]. / Maldescensus testis und Hodentumoren. Eigene Erfahrungen.

In 236 own patients suffering from malignant testicular tumors a maldescensus testis was evaluated in childhood. Because of increased risk of cancer in maldescended testis attention should be paid also after successful orchiopexy.

[Hydrochlorothiazide in the metaphylaxis of recurrent calcium oxalate lithiasis]. / Hydrochlorothiazide in der Metaphylaxe der rezidivierenden Kalzium-oxalatlithiasis.

The main indication for the application of Disalunil in the convalescent care of recidive calcium-lithiasis patients is renal hypercalciuria. Treatment with 50 mg Disalunil/d reduced the rate of recidivation by two thirds. Even during long-term application of this therapy over 3-7 years, side effects were slight and did not require any cessation of therapy.

[Diagnosis of absorptive hypercalciuria]. / Zur Diagnostik der absorptiven Hyperkalziurie.

Reference is made to the significance of hypercalciuria in the aetiology of calcium oxalate lithiasis. Differentiation between the various forms of hypercalciuria allows the therapy to be suited to the respective causes. In order to measure intestinal calcium absorption the authors examined serum samples from 22 patients after oral administration of Ca47; in 13 cases absorptive calciuria was diagnosed.

Laparoscopic lymphocele drainage after renal transplantation.

Lymphoceles are among the most frequent surgical complications after renal transplantation. We performed laparoscopic drainage in 5 patients with a large lymphocele in the small pelvis after successful kidney transplantation.

Percutaneous management of urolithiasis after kidney transplantation. Report of a case and review of the literature.

Urolithiasis is one of the least common urological complications after kidney transplantation, but it remains an important cause of deterioration of graft function. We report a case managed by percutaneous nephrostolithotomy and review the literature.

[Treatment of idiopathic varicocele in children and adults by occlusion of the testicular vein with a detachable balloon]. / Zur Behandlung der idiopathischen Varikozele bei Kindern und Erwachsenen durch Okklusion der Vena testicularis mit ablösbaren Ballons.

The results of varicocele treatment by balloon occlusion of the testicular vein in 22 children and 29 adults are compared with the results after operative ligation of the testicular vein in 95 patients. In 6 out of 22 children (27%) the varicocele persisted after balloon occlusion, compared with 3 out of 29 adult patients (10%). These results in adults are comparable to the results after operative ligation of the testicular vein, whereas the complication rate was significantly lower after balloon occlusion in comparison with operative treatment.

Role of laparoscopic surgery in pediatric urology.

OBJECTIVES: In our clinic, laparoscopy was introduced in 1987 for the exploration of non-palpable testes and since 1991 it has also been applied with therapeutic aims. We present our experience with this minimally invasive technique in pediatric patients. PATIENTS AND METHODS: Between May 1987 and September 1996, 219 laparoscopic procedures were performed in children. All children received general anesthesia. Positioning of the patient on a rotatable and tiltable operating table is very important. RESULTS: All laparoscopic interventions were well tolerated in children. The operative time for exploration of a nonpalpable testis ranged from 10 to 30 min, and for varix ligation from 15 to 30 min. In nephrectomy and nephroureterectomy cases 80-150 min were required. The excision of the urachal remnant and the drainage of lymphocele took between 30 and 70 min. No immediate postoperative complications were observed. Mobilization and oral intake were routinely carried out on the day of surgery. The children required little or no postoperative pain medication. CONCLUSION: Laparoscopy has been found to be the most reliable diagnostic tool in evaluating nonpalpable testes within the pediatric population. This approach enables subsequent therapy of laparoscopic orchiectomy, primary laparoendoscopic orchidopexy, or laparoscopically assisted two-stage Fowler-Stephens maneuver. Laparoscopic varix ligation is a simple and highly effective treatment modality for the pubescent male with a symptomatic varicocele. To date, the recurrence rate is 1.8% based on 80 patients followed for over 1 year. Fenestration of lymphoceles following renal transplantation has been found to be as efficaciously treated with laparoscopy as with open surgery. Laparoscopic nephrectomy and/or nephroureterectomy are technically demanding procedures and should only be performed by an experienced laparoscopic surgical team to minimize the complication rate. At the present time, the intraoperative costs of laparoscopic surgery are greater than with open surgery due to the use of disposable instrumentation and longer operating room times. However, minimally invasive surgery continues to gain a greater and more important role in the field of pediatric urology.