On-site CAD templates reduce surgery time for complex craniostenosis repair in infants: a new method.

INTRODUCTION: The surgical correction of craniostenosis in children is a time-consuming and taxing procedure. To facilitate this procedure, especially in infants with complex craniostenosis, we refined the computer-aided design and manufacturing technique (CAD/CAM) based on computed tomography (CT)-generated DICOM data. We used cutting guides and molding templates, which allowed the surgeon to reshape and fixate the supraorbital bar extracorporeally on a side table and to control the intracorporal fit without removing the template. METHOD AND PATIENTS: To compare our traditional concept with the possibility of preoperative virtual planning (PVP) technique, the surgical treatment and courses of 16 infants with complex craniostenosis following fronto-orbital advancement (FOA) (age range 8-15 months) were analyzed in two groups (group 1: traditional, control group n = 8, group 2: CAD/CAM planned, n = 8). RESULTS: While in both groups, the head accurately reshaped postoperatively during the follow-up; the CAD group 2 showed a significantly shorter operating time with a mean of 4 h 25 min compared with group 1 with a mean of 5 h 37 min (p = 0.038). Additionally, the CAD group 2 had a significantly lower volume of blood loss (380 ml vs. 575 ml mean, p = 0.047), lower blood transfusion volume (285 ml vs. 400 ml mean, p = 0.108), lower fresh frozen plasma (FFP) volume (140 ml vs. 275 ml mean, p = 0.019), shorter stay in the pediatric intensive care unit (PICU) (3 vs. 5 days mean (p = 0.002), and shorter total length of hospital stay (6 days vs. 8 days mean, p = 0.002). CONCLUSION: CAD/CAM cutting guides and templates offer optimizing operative efficiency, precision, and accuracy in craniostenosis surgery in infants. As shown in this single-center observational study, the use of on-site templates significantly accelerates the reconstruction of the bandeau. The virtual 3D planning technique increases surgical precision without discernible detrimental effects.

Changes in the facial soft-tissue profile after mandibular orthognathic surgery.

OBJECTIVES: To investigate the correlation between soft- and hard-tissue changes after mandibular orthognathic surgery, to generate precise prognostic values for the esthetic treatment outcome of the facial profile. MATERIAL AND METHODS: In this retrospective study, sagittal changes in the facial soft tissue profile in relation to surgical changes in hard structures after mandibular osteotomy were examined. The sample population included 144 reported adult patients aged 17-50 years who had received combined mandibular orthognathic surgery and orthodontic treatment at the Department of Orthodontics, Ludwig-Maximilians University of Munich, Germany. Both mandibular advancement and mandibular setback cases in monognathic and bignathic osteotomy procedures were included. All subjects had undergone rigid fixation. A cephalometric analysis of presurgical and postsurgical cephalograms was performed, and the correlations between hard-tissue and soft-tissue change ratios were evaluated using a bivariate linear regression analysis. RESULTS: The lower lip, represented by the landmark Labrale inferius (Li), followed the lower incisor (Ii) by 77%. The soft-tissue B-point (B') followed the B-point (B) by 97% and the soft-tissue Pogonion (Pg') followed the Pogonion (Pg) by 97% in a linear correlation. CONCLUSION: The scatterplots show a distinct linear correlation and no significant difference in the direction of the movement. A wider spread for the lower lip (Li/Ii) indicates a lower predictability of the expected lip position, whereas a narrow spread of the chin values (B'/B and the Pg'/Pg) reveals a very good predictability of the postoperative chin position. CLINICAL RELEVANCE: This study contributes valid data for the soft-tissue profile prediction in orthognathic surgery.

Separation of centrifuged whole blood and pooled buffy coats using the new CompoMat G5: 3 years experience.

BACKGROUND AND OBJECTIVES: Semi-automatic separation devices can be used for the separation of centrifuged whole blood into leucoreduced red cell concentrate (LR-RCC), plasma and buffy coat (BC) and to make platelet concentrates (PC) from pooled BCs. To improve and to obtain a more uniform and standardized process, the CompoMat G5 (Fresenius) was implemented, a new-generation semi-automated device. MATERIALS AND METHODS: Uniform programs for WB separation and preparation of PCs were validated, using collection and pooling systems with CompoFlow (CF) closures, which can be automatically opened by the G5. Cell counts were performed and compared with historic data of blood components obtained with the formerly used Compomat G4 and Optipress II. After implementation, different adjustments were made to improve product quality. RESULTS: Leucoreduced red cell concentrates (280 ± 15 ml, 53 ± 5 g haemoglobin) and plasma (317 ± 16 ml) met European guidelines. BCs (48 ± 2 ml, 0·42 ± 0·05 l/l, 93 ± 25 × 10(9) platelets) contained a similar platelet (PLT) content as BC prepared before with the Compomat G4. A relatively high percentage (4-6%) of PCs (330 ± 17 ml, 330 ± 50 × 10(9) PLT, 0·12 ± 0·21 × 10(6) leucocytes) contained <250 × 10(9) PLT which was the subject of improvement studies. After implementation, RCC and BC discard decreased and workload was less. Operator complaints were also less frequent. CONCLUSION: The same high-quality blood components can be prepared by using the CompoMat G5 as previously with other semi-automated devices. Improvement was realized by automation of the opening process by the use of collection systems with CF closures, which led to a decrease in discarded units and workload.

Late-gestation heat stress in Holstein dams programs in utero development of daughter's germline, triggering skin and hair morphology adaptations of granddaughters.

Homeostasis and thermoregulation are influenced by the interplay of hair coat and skin characteristics. Our previous work indicated that hair and skin adaptations, triggered by in utero heat stress, affect thermoregulation in postnatal life. Herein, we investigate multigenerational carry-over effects of late-gestation heat stress on hair and skin characteristics beyond the first generation. Pregnant Holstein dams (F0, grand-dams) were heat stressed (HT, shade, n = 41) or provided active cooling (CL, shade, fans, and water soakers, n = 41) for the last 56 d of gestation during summer (temperature-humidity index ≥68). The first generation of heifers (F1, daughters) who were in utero heat stressed (HTF1, n = 36) or not (CLF1, n = 37) were born and raised as a cohort from birth to first calving. Thirty second-generation heifers (F2, granddaughters), born to HTF1 (HTF2, n = 12) and CLF1 (CLF2, n = 18), were raised as a cohort from birth to 70 d of age. Hair samples and skin biopsies from HTF2 and CLF2 were collected on postnatal d 70 (n = 6/group). Hair samples were subdivided into topcoat and undercoat, and skin tissue was fixed for ~18 h in 10% formalin, dehydrated, paraffin-embedded, sectioned, and stained with hematoxylin and eosin to visualize morphology. Variables analyzed included hair length and diameter; stratum corneum cross-sectional area and thickness; epidermis thickness; sweat gland depth, number, cross-sectional area, and average size; and sebaceous gland number, cross-sectional area, and average size. Measurements were performed using the ImageJ software and analyzed using PROC MIXED in SAS (SAS Institute Inc.). Hair length and diameter tended to be shorter and thicker in HTF2, compared with CLF2. The HTF2 skin had smaller stratum corneum cross-sectional area and tended to a thinner epidermis. to CLF2, HTF2 skin had more but smaller sebaceous glands, whereas no differences in sweat glands were observed. In summary, we report phenotypic alterations in hair and skin characteristics of granddaughters. Whether these adaptations grant improved postnatal thermoregulatory ability for the granddaughters remains to be investigated.

[Development of an ICF-based clinical practice guideline for the assessment of function in head and neck cancer]. / Entwicklung eines ICF-basierten Leitfadens für die Beurteilung funktioneller Aspekte bei Kopf-Hals-Tumoren.

BACKGROUND: Functional outcome following head and neck cancer is not regularly assessed in a standardized way in clinical practice. Clinical trials assessing functional outcome apply many different instruments. Therefore, results are not always comparable and have limited clinical implications. Aim of this study was the identification, interdisciplinary evaluation, and recommendation of functional outcome instruments for use in clinical practice and clinical trials in patients with HNC. MATERIAL: Preparatory studies came up with a shortlist of outcome instruments on the basis of previously determined criteria. An interdisciplinary expert group evaluated these instruments and decided on which ones can be recommended for use in 3 application areas: screening, therapy evaluation/planning, and clinical trials. Decision making health professionals included physicians (ENT and maxillofacial surgeons, radiotherapists, oncologists), medical psychologists, speech and language therapists, physiotherapists, and social workers. RESULTS: 98 instruments were presented at the consensus conference. Altogether 21 participants recommended for each of the 3 application areas a basic set of measures for the evaluation of impairment in 6 functional domains: follow-up therapy monitoring, pain, ingestion, voice/speaking, other organic problems, and psychosocial problems. CONCLUSION: A multi-professional expert's pool discussed and adopted recommendations for the use of functional outcome instruments in clinical praxis and/or in research. The re-commended instruments are now available for use in clinical routine.

[Maxillofacial fractures: midface and internal orbit. Part 2: therapeutic options]. / Maxillofaziale Frakturen: Mittelgesicht und interne Orbita. Teil 2: Therapieoptionen.

While the state of the art of clinical assessment and imaging techniques were described in Part 1, this contribution presents a systematic review of the surgical treatment principles in the management of midface and internal orbit fractures from initial care to definitive treatment, including illustrative case examples. New developments and advances are characterized by limited versus extended surgical approaches, by standardization of osteosynthesis principles with regard to three-dimensional buttress reconstruction, by newly developed individualized implants such as titanium meshes and, especially for complex fracture patterns, by critical assessment of anatomical reconstruction through intraoperative endoscopy, as well as intraoperative and postoperative imaging. Newly developed resorbable soft tissue anchors can be used both for ligament and soft tissue resuspension in order to reduce ptosis effects in the cheeks and nasolabial area to achieve facial aesthetics similar to those prior to the injury.

Changes in the facial soft tissue profile after maxillary orthognathic surgery.

OBJECTIVES: To compare the changes of the soft tissue profile in relation to the displacement of the underlying hard structures in maxillary orthognathic surgery and to contribute to the esthetic prediction of the facial profile after surgical procedures. MATERIALS AND METHODS: We analyzed the sagittal changes in the facial soft tissue profile related to surgical changes in skeletal structures after maxillary osteotomy in a retrospective study. The study sample comprised 115 adult patients between the ages of 18-50 years who had undergone maxillary orthognathic surgery and interdisciplinary orthodontic treatment at the Department of Orthodontics, Ludwig-Maximilians University of Munich, Germany. LeFort I osteotomy cases in both maxillary monognathic and bignathic osteotomy procedures were included. All subjects had received rigid fixation. A cephalometric analysis of presurgical and postsurgical cephalograms was performed and the correlations between hard tissue and soft tissue change ratios were evaluated using a bivariate linear regression analysis. A vertical line through the landmark sella (S) perpendicular to the nasion-sella line (NSL) served as the reference plane. RESULTS: The subnasale (Sn) followed the A point (A) by 57%, the soft tissue A point (A') followed the A point (A) by 73% and the upper lip, represented by the landmark labrale superius (Ls) followed the upper incisor (Is) by 73%; all three in a linear correlation with a mean prediction error of nearly 2 mm. CONCLUSION: The scatterplots show a linear correlation with a wide spread for all three pairs of reference points. The wide spread and the high prediction error of almost 2 mm indicate low predictability of the expected lip position and Sn.

[Maxillofacial fractures: midface and internal orbit : Part 1: classification and diagnosis]. / Maxillofaziale Frakturen: Mittelgesicht und interne Orbita : Teil 1: Klassifikation und Diagnostik.

Fractures of the midface and internal orbit occur isolated or in combination with other injuries. Frequently, the patients are first seen in emergency rooms responsible for the coordination of initial diagnostic procedures, followed by the transfer to specialties for further treatment. It is, therefore, important for all colleagues in traumatology to understand the basic principles of injuries to the midface. Thus, the aim of this article is the description of the anatomy and the current classification systems in use, the related clinical symptoms, and the essential diagnostic measures to obtain precise information about the injury pattern. Issues for treatment will be illustrated and discussed in "Part 2" of this article.

Description and evaluation of a new approach on pre-clinical implant dentistry education based on an innovative simulation model.

INTRODUCTION: Predominantly theoretical courses are employed to teach German dental students in implant dentistry at pre-clinical stage. As implant dentistry is an important part of the clinical treatment spectra, practical implementation of this field at an early stage of education seems to be appropriate. By a newly developed interdisciplinary implant dentistry course, students should assess an improved competence level as well as first practical experiences in the field of implant dentistry at the pre-clinical stage of their education. MATERIALS AND METHODS: Interdisciplinary implant dentistry education was integrated in the final pre-clinical course Phantom II at the Department of Prosthodontics, LMU, Munich. In total 120 pre-clinical students participated at the implant dentistry education course. After theoretical introduction into implant surgery and implant prosthetics, 30 simulation units were employed for the practical training of the participants. All important treatment steps were carried out by the students under instruction by the supervisors, including interdisciplinary planning, the use of the drilling template, the template guided insertion of two implants, as well as the integration of two ball attachments into a pre-existing full denture. After the course participants were asked by questionnaire about the quality of the course and their personal opinion. RESULTS: The course received an extraordinary positive feedback. In total 108 students evaluated the course with the overall grade of 1.68 according to the German school-mark system (1 = excellent, 6 = unsatisfactory). Also the single parts of the course were voted constantly positively. CONCLUSION: The aim of this first interdisciplinary course for pre-clinical students was to enhance competence level and practical implementation of implant dentistry at an early stage of education. Participants' comments and suggestions on the questionnaires demonstrated the positive response and the general interest in this form of dental education, as well as the demand for further development of training in this field.

[Severe bacterial soft tissue infections in the head and neck region : Overview of the causes, pathogenesis, diagnostics, treatment and possible sequelae]. / Schwere bakterielle Weichgewebeinfektionen im Kopf- und Halsbereich : Ein Überblick über die Ursachen, Pathogenese, Diagnostik, Therapie und mögliche Folgen.

BACKGROUND: This article gives an overview of severe and fulminant infections of the head and neck region. The focus is on the treatment, diagnostics and causes of abscesses, phlegmon and necrotizing fasciitis. OBJECTIVE: Despite guideline-conform treatment soft tissue infections of the head and neck can spread rapidly and be life-threatening. MATERIAL AND METHODS: Analysis and discussion of basic research and expert recommendations, case reports. RESULTS: While purulent tonsillitis is the primary cause of severe bacterial soft tissue infections in children, dental infections are the leading cause in adults. The infections often spread along anatomic spaces and can extend into the brain or mediastinum and a hematogenic dissemination is also possible. Multiple operations and combined antibiotic treatment are often required as well as additional treatment, such as intubation, tracheotomy and dialysis. Late or early onset complications can occur and reconstructive measures might be necessary in addition to rehabilitation. CONCLUSION: Severe bacterial soft tissue infections can be still life-threatening despite guideline-conform treatment and are associated with a high mortality especially in high-risk patients even with intensive medical care. They can lead to disfiguration and loss of function resulting in a greatly reduced quality of life. Rapid diagnostics and therapy are essential for successful treatment.

Continued benefit of coronary stenting versus balloon angioplasty: one-year clinical follow-up of Benestent trial. Benestent Study Group.

OBJECTIVES: This study sought to determine the 1-year clinical follow-up of patients included in the Benestent trial. BACKGROUND: The Benestent trial is a randomized study comparing elective Palmaz-Schatz stent implantation with balloon angioplasty in patients with stable angina and a de novo coronary artery lesion. Seven-month follow-up data have shown a decreased rate of restenosis and fewer clinical events in the stent group. It is not established whether this favorable clinical outcome is maintained for longer periods or whether coronary stenting defers restenosis and its subsequent clinical manifestations. METHODS: To clarify this uncertainty, we updated clinical information on all but 1 of 516 patients enrolled in the Benestent trial (257 in balloon group, 259 in stent group) at least 12 months after the intervention. Major clinical events (primary clinical end point) were tabulated according to the intention to treat principle and included death, the occurrence of a cerebrovascular accident, myocardial infarction, the need for bypass surgery or a further percutaneous intervention in the previously treated lesion. RESULTS: After 1 year, no significant differences in mortality (1.2% vs. 0.8%), stroke (0.0% vs. 0.8%), myocardial infarction (5.0% vs. 4.2%) or coronary bypass graft surgery (6.9% vs. 5.1%) were found between the stent and balloon angioplasty groups, respectively. However, the requirement for a repeat angioplasty procedure was significantly lower in the stent group (10%) than the balloon angioplasty group (21%, relative risk [RR] 0.49, 95% confidence interval [CI] 0.31 to 0.75, p = 0.001), and overall primary end points were less frequently reached by stent group patients (23.2%) than those in the balloon group (31.5%, RR 0.74, 95% CI 0.55 to 0.98, p = 0.04). No differences were found between groups with respect to functional class angina and prescribed medication at the time of follow-up. CONCLUSIONS: These clinical follow-up data show that the benefit of elective native coronary artery stenting in patients with stable angina is maintained to at least 1 year after the procedure and results in a significantly reduced requirement for repeat intervention.

Usefulness of quantitative and qualitative angiographic lesion morphology, and clinical characteristics in predicting major adverse cardiac events during and after native coronary balloon angioplasty. CARPORT and MERCATOR Study Groups.

Major, adverse cardiac events (death, myocardial infarction, bypass surgery and reintervention) occur in 4 to 7% of all patients undergoing coronary balloon angioplasty. Prospectively collected clinical data, and angiographic quantitative and qualitative lesion morphologic assessment and procedural factors were examined to determine whether the occurrence of these events could be predicted. Of 1,442 patients undergoing balloon angioplasty for native primary coronary disease in 2 European multicenter trials, 69 had major, adverse cardiac procedural or in-hospital complications after > or = 1 balloon inflation and were randomly matched with patients who completed an uncomplicated in-hospital course after successful angioplasty. No quantitative angiographic variable was associated with major adverse cardiac events in univariate and multivariate analyses. Univariate analysis showed that major adverse cardiac events were associated with the following preprocedural variables: (1) unstable angina (odds ratio [OR] 3.11; p < 0.0001), (2) type C lesion (OR 2.53; p < 0.004), (3) lesion location at a bend > 45 degrees (OR 2.34; p < 0.004), and (4) stenosis located in the middle segment of the artery dilated (OR 1.88; p < 0.03); and with the following postprocedural variable: angiographically visible dissection (OR 5.39; p < 0.0001). Multivariate logistic analysis was performed to identify variables independently correlated with the occurrence of major adverse cardiac events. The preprocedural multivariate model entered unstable angina (OR 3.77; p < 0.0003), lesions located at a bend > 45 degrees (OR 2.87; p < 0.0005), and stenosis located in the middle portion of the artery dilated (OR 1.95; p < 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Stenting of "unprotected" left main coronary artery stenoses: early and late results.

OBJECTIVE: To assess short and long term efficacy of coronary stent implantation for unprotected left main coronary artery stenosis. DESIGN: Retrospective follow up study. SETTING: Tertiary referral centre for interventional cardiology and cardiac surgery. PATIENTS: Eighteen consecutive patients (12 men; age 70.8 years) between May 1993 and July 1996. Ten patients presented with stable angina and underwent the procedure electively, eight patients presented either with unstable angina or myocardial infarction and underwent the procedure in emergency. INTERVENTION: Johnson and Johnson Palmaz-Schatz stents were used in 16 patients, and a Microstent and a Gianturco-Roubin in one patient each. An intra-aortic balloon pump was prophylactively used for two patients in the elective group. In the acute group, six required an intra-aortic balloon pump. MAIN OUTCOME MEASURES: Procedural success rate and major adverse cardiac events. RESULTS: Successful stent implantation was achieved in all patients. In the elective group, no major adverse cardiac event occurred during the procedure, but one patient had to undergo repeated angioplasty before discharge. All patients of the elective group were discharged alive and there has been one non-cardiac death during a follow up of (mean (SD)) 10 (4) months. In the emergency group, one patient died during the procedure, one patient developed a non Q-wave myocardial infarction, one patient underwent emergency coronary bypass surgery, while another patient died suddenly before hospital discharge. Six patients of the emergency group were discharged alive and there has been one non-cardiac death during a follow up of 7 (4) months. CONCLUSIONS: Elective stent implantation for unprotected left main coronary artery stenosis is safe and effective in selected stable patients. Urgent stent implantation, however, cannot be considered as a definitive procedure in emergency situation.

[Computed tomography of acute bacterial nephritis]. / Computertomographie bei akuten bakteriellen Nierenentzündungen.

Five case reports are used to illustrate that it is possible by computed tomography to differentiate between acute diffuse, acute focal and abscess-forming types of renal infection. In acute diffuse renal inflammatory disease, intravenously injected contrast medium remains in various parts of the renal tissue after an interval of two to six hours following injection. Acute focal inflammatory disease and abscesses produce localised hypodense or isodense lesions. Sequential increase in density following a contrast bolus injection permits the distinction of focal nephritis from an abscess. These findings provides information concerning the type and duration of treatment.

[Fournier's gangrene]. / Die Fournier'sche Gangrän.

Today Fournier's gangrene ranks among necrotizing fasciitis. Most of the cases reveal the origin of the disease (proctogenic, urologic, gynecologic). Untreated, the polybacterial synergistic infection will overwhelmingly spread along anatomically defined fascias of the pelvic floor. Thus the lethality rate is high, especially in patients with risk factors i.e. diabetes, alcoholism, arterial occlusive disease, chronic consumptive disorders and obesity. Only by instant and radical surgical excision of the total gangrenous tissue the spreading of the disease and the developing of sepsis can be stopped together with calculated antibiotic therapy and intensive care. Mutilating operations (i.e. penectomy, orchiectomy) are seldom necessary; thus plastic reconstructions will show good results both in function and cosmetic. Based on the experience with 6 patients, a pathogenic concept, concerning both diagnosis and therapy, is presented: after radical emergency surgery in the first risky stage, an elective approach can safely be performed in a second stage for the repair of functional lesions.

[Urological diseases causing renal hypertension (author's transl)]. / Renale Hypertonie als Folge urologischer Erkrankungen.

Based on experimental and clinical findings the publication demonstrates the pathogenesis of renal hypertension. The diagnostic and prognostic value of split renal function test and a split estimation of plasma renin activity is pointed out for the surgical management of renal hypertension. New urosurgical methods for the correction of renovascular diseases are described.

[Complexity-oriented surgical strategies in vesicovaginal fistulas]. / Komplexitätsorientierte Operationsstrategien bei vesiko-vaginalen Fisteln.

Since 1975 a total of 55 patients with vesicovaginal fistulas have undergone surgery at the Clinic of Urology, University of Saarland, Homburg/Saar. A majority (55%) of the cases were complicated. In 9 cases supravesical urinary diversion was necessary. Successful closure of the fistula was achieved in 45 patients (81.8%); only in one case is the fistula still present. In 5 patients with uncomplicated fistulas successful closure was accomplished by a vaginal approach. In the presence of complications, e.g., previous radiotherapy or accompanying lesions of the ureter or rectum, a transvesical/transabdominal approach was preferred; surgery was successful in 93.3% of such cases.

[Microsurgery in urology]. / Mikrochirurgie in der Urologie.

The use of microsurgical techniques offers operative perspectives also in urology. Microsurgery is indicated for reconstructive vascular surgery in the kidneys, in cases of erectile impotence, and in high maldescended testicles, for recanalisation of the vas deferens and in early childhood for plasty surgery of malformations of the upper urinary tract and such of the male genitals. Certain indications are presented under reference to own clinical experiences.

[Selective sacral nerve blockade in the treatment of detrusor hyperreflexia of the bladder]. / Die selektive Sakralnervenblockade zur Behandlung der Detrusorhyperreflexie der Harnblase.

Hyperreflexive detrusor instability causes severe impairment of the patients private and professional life. Involuntary detrusor contractions lead to incontinence. The results of previous pharmacological and operative therapeutic procedures are unsatisfactory. 22 cases with idiopathic hyperreflexive detrusor instability were cured by selective local anaesthesia of both sacral roots S3. The follow-up period ranges from 4 months to 2 years. In case with neurogenic detrusor instability local anaesthesia of the sacral roots S3 has no permanent effect. But in 4 such cases it was possible to reach continence by permanent interruption of the roots S3 using phenolglycerin injections. Unavoidably this success, which enables social rehabilitation, results in voiding disturbance of the bladder which makes voiding by manual bladder compression or even catheterization necessary.

[Micturition disorder as a sequela of sacral autonomic diabetic neuropathy]. / Harnblasenentleerungsstörung als Folge einer sakralen autonomen diabetischen Neuropathie.

Diabetic neuropathy may manifest itself also in the autonomous nervous system and thus lead to a functional disorder of the urinary bladder. Urodynamic studies carried out in 11 diabetic patients with unclear bladder dysfunction allowed 2 forms of bladder anomalies to be identified: 1. detrusor hyperreflexia, 2. hyporeflexia and areflexia of the detrusor. Whereas hyperreflexia is clinically characterised by signs of motor urgency, hyporeflexia is mainly identifiable by residual urine formation and recurrent infections of the urinary tract. Therapy depends on the type of dysfunction and consists of physiotherapeutic measures, drug therapy and occasionally surgery.