[Hernia surgery in urology. Part 2: parastomal, trocar and incisional hernias - fundamentals of clinical diagnostics and treatment]. / Hernienchirurgie in der Urologie : Teil 2: Parastomale Hernien, Trokarhernien, Narbenhernien - Grundlagen der Diagnostik und operativen Therapie.

Hernias are a common occurrence with a correspondingly huge clinical and economic impact on the healthcare system. Parastomal and trocar hernias are rare in routine urological work. The therapy of parastomal hernias remains problematic but basically the surgeon is able to use conventional techniques with suture repair or procedures with mesh implantation. The conventional parastomal hernia repair with mesh can be classified into sublay, onlay and intraperitoneal techniques. Furthermore, a relocation of the stoma is possible. Trocar hernias represent a rare but hazardous complication. Due to the increase in keyhole surgery there is also the danger of a rise in their occurrence. Incisional hernias occur frequently in patients who have undergone laparotomy and for repair different surgical techniques and types of meshes are available. This article presents an overview of the epidemiology, pathogenesis, clinical symptoms, diagnostic and therapy of parastomal, trocar and incisional hernias.

[Hernia surgery in urology: part 1: inguinal, femoral and umbilical hernias - fundamentals of clinical diagnostics and treatment]. / Hernienchirurgie in der Urologie : Teil 1: Leistenhernien, Schenkelhernien, Nabelhernien - Grundlagen der Diagnostik und der operativen Therapie.

Hernias are a common occurrence with correspondingly huge clinical and economic impacts on the healthcare system. The most common forms of hernia which need to be diagnosed and treated in routine urological work are inguinal and umbilical hernias. With the objective of reconstructing and stabilizing the inguinal canal there are the possibilities of open and minimally invasive surgery and both methods can be performed with suture or mesh repair. Indications for surgery of umbilical hernias are infrequent although this is possible with little effort under local anesthesia. This article presents an overview of the epidemiology, pathogenesis, clinical symptoms, diagnostics and therapy of inguinal, femoral and umbilical hernias.

Quality of life in patients with muscle invasive and non-muscle invasive bladder cancer.

PURPOSE: Compared to the literature on other malignancies, data on quality of life (QoL) in bladder cancer are sparse. This study sought answers to the following questions: In what QoL domains do patients with bladder cancer differ from the general population? Do patients with radical cystectomy differ in QoL compared to those who received conservative treatment? Do patients with neobladder generally have better QoL compared to patients with other diversion methods? METHODS: At the beginning of inpatient rehabilitation, N = 823 patients with bladder cancer were assessed. Data of a representative community sample (N = 2037) were used for comparison. The questionnaire EORTC QLQ-C30 was used to measure QoL. Multivariate linear regression models were computed to investigate differences between groups. RESULTS: Patients with both non-muscle invasive and muscle invasive bladder cancer reported significantly more problems and worse functioning than the general population. Radiotherapy is associated with clinically relevant more pain, dyspnoea, constipation, appetite loss and decreased social functioning while chemotherapy is associated more with dyspnoea. Cystectomy patients reported more fatigue, appetite loss and decreased role functioning. Male patients ≥70 years with conduit experienced more sleep and emotional problems. These effects of urinary diversion were not observed in women and younger patients. CONCLUSIONS: Patients with bladder cancer experience various QoL concerns at the beginning of inpatient rehabilitation. These problems can partly be explained by the type of treatment the patients receive. Type of urinary diversion is relevant for QoL in subgroups of patients.

[Small renal mass]. / Der kleine Nierentumor.

The frequent application of ultrasound and radiological imaging for non-urological indications in recent years has resulted in an increase in the diagnosis of small renal masses. The treatment options for patients with a small renal mass include active surveillance, surgery (both open and minimally invasive) as well as ablative techniques. As there is a risk for metastatic spread even in small renal masses surgical extirpation remains the treatment of choice in most patients. Ablative procedures, such as cryoablation and radiofrequency ablation are appropriate for old and multi-morbid patients who require active treatment of a small renal mass. Active surveillance is an alternative for high-risk patients. Meticulous patient selection by the urologist and patient preference will determine the choice of treatment option in the future.

[Sacral neuromodulation in urology - development and current status]. / Sakrale Neuromodulation in der Urologie - Entwicklung und aktueller Stand.

Sacral neuromodulation (SNM) in urology is employed to treat refractory lower urinary tract dysfunction as well as chronic pelvic pain. Electrical stimulation of the sacral afferents (S2 - S4) causes activation and conditioning of higher autonomic and somatic neural structures and thereby influences the efferents controlling the urinary bladder, the rectum and their related sphincter systems. It is therefore possible to treat overactivity as well as hypocontractility and functional bladder neck obstruction. SNM treatment is conducted biphasically. Initially, test electrodes are placed to evaluate changes in micturition and pain parameters. If, in this first phase - called peripheral nerve evaluation (PNE test) - sufficient improvements are observed, the patient progresses to phase two which involves implantation of the permanent electrodes and impulse generator system. In recent years, the "two stage approach" with initial implantation of the permanent electrodes has been favoured as it increases treatment success rates. Long-term success rates of SNM vary significantly in the literature (50 - 80 %) due to heterogeneous patient populations as well as improved surgical approaches. With the introduction of "tined lead electrodes" (2002), tissue damage is reduced to a minimum. Technical innovation, financial feasibility (reimbursed in Germany since 2004) and wider application, especially in otherwise therapy-refractory patients or complex dysfunctions of the pelvis, have established SNM as a potent treatment option in urology.

Response shift in the assessment of anxiety, depression and perceived health in urologic cancer patients: an individual perspective.

The assessment of quality of life in cancer patients is hampered because patients may change their frames of reference during the course of the disease. The aim of this study was to test individual differences in these response shift effects. Urologic cancer patients (n= 275) were examined during the stay in the hospital (T1), 2 weeks later (T2) and 3 months later (T3). Furthermore, at T3 they were asked to retrospectively assess their situation at T1 (then-test). The difference between this retrospective assessment and the original assessment at T1 was used to determine the response shift effect (recalibration). Anxiety (Generalized Anxiety Disorder Questionnaire-2), depression (Patient Health Questionnaire-2) and health dissatisfaction (Questionnaire on Life Satisfaction) were obtained at all points in time. The effect sizes of the mean response shift effects (recalibration) ranged between 0.26 and 0.48. Nevertheless, a large proportion of the sample showed no response shift (22-38%) or even negative response shift effects (20-30%). There were significant correlations among the response shift measures of the domains (anxiety, depression and health dissatisfaction) with coefficients between 0.29 and 0.51. The results indicate that response shift should not only be assessed on the mean score level, since it is also a dimension of individual difference.

Hydronephrosis Resulting from Bilateral Ureteral Stenosis: A Late Complication of Polyoma BK Virus Cystitis?

We report here a case of acute lymphoblastic leukemia in remission presenting a late-onset bilateral hydronephrosis probably due to polyoma BK virus-induced proliferation of bladder endothelium on both ostii. The diagnosis was made virologically by BK virus Polymerase Chain Reaction (PCR) detection in the absence of any other bladder disease. Awareness of this late complication is necessary not only in patients after renal transplantation but also in patients after hematopoietic stem cell transplantation from matched unrelated donor.

[Adrenal tumors. Principles of diagnostics and operative treatment]. / Nebennierentumoren. Grundlagen der Diagnostik und operativen Therapie.

Adrenal masses are very heterogeneous and comprise benign or malignant tumors, unilateral or bilateral masses and variable endocrine activity. Because of these attributes adrenal gland masses are a clinical challenge. This article gives a summary of diagnostic steps and indications for adrenal surgery including perioperative management.

[Functional anatomy of the male continence mechanism]. / Funktionelle Anatomie des männlichen Kontinenzmechanismus.

The basic structures and organs contributing to continence in men are far less well investigated than in women. This concerns anatomical and functional aspects as well. Especially the cooperation of single components and the dynamic anchoring in the pelvic floor require further investigation. An improved anatomical-functional interpretation is needed to generate therapeutic concepts orientated at the physiology of the bladder neck.Therefore, the focus of anatomical investigations should be on the external sphincter which is the main muscle responsible for urethral closure as well as on the connective tissue, smooth muscular and neuronal structures in the pelvis. The smooth muscular structures involved are the internal sphincter, the inner parts of the external sphincter, the urethral longitudinal musculature, and parts of the centrum perinei and of the ventral suspension apparatus which fixes the position of the bladder neck and seems to be vital for continence and initiation of micturition. These new findings imply an integral concept for men as was developed for women. A first step in this regard would be a consistent and updated anatomical nomenclature.

[New insights in the differential diagnosis of bladder pain syndrome]. / Neue Erkenntnisse zur Differenzialdiagnostik des Bladder-Pain-Syndroms.

The diagnosis of bladder pain syndrome/interstitial cystitis (BPS/IC) is challenging, since pathogenetic mechanisms and the definition of clinical relevant parameters are still under lively discussion. The criteria recently proposed by the European Society for the Study of Interstitial Cystitis (ESSIC) define a collective of patients based on the cardinal symptom of bladder pain which is heterogeneous, and therefore cannot receive standardised consistent therapy. Thus an extended diagnosis based on molecular markers seems to be indicated to render individual pharmacotherapy possible, and to contribute to elucidation of BPS/IC pathogenesis. For this purpose we feel the vital need for taking a bladder biopsy. The diagnosis of BPS/IC should rely on 3 "columns": (1) clinical diagnostics; (2) histopathology; (3) molecular diagnostics/protein expression. Since a significant contribution of the 3 functional units of the bladder to the pathophysiology is most evident, the examinations should ideally include urothelium, lamina propria, and detrusor musculature. Generation of receptor profiles of the detrusor muscle represents a first attempt to define a diagnostic tool for the individualisation of BPS/IC pharmacotherapy. Other factors, e.g., beta-hCG expression in the urothelium, need further evaluation. Extended BPS/IC diagnostics could be realistically integrated into routine patient care within a clinic/laboratory network.

[Myofibroblasts and afferent signalling in the urinary bladder. A concept]. / Myofibroblasten und die afferente Signalverarbeitung in der Harnblase. Ein Konzept.

Afferent signal transduction in the urinary bladder is still not clearly understood. An increasing body of evidence supports the view of complex interactions between urothelium, suburothelial myofibroblasts, and sensory nerves. Bladder tissue from tumour patients was used in this study. Methods included confocal immunofluorescence, polymerase chain reaction, calcium imaging, and fluorescence recovery after photobleaching (FRAP).Myofibroblasts express muscarinic and purinergic receptors. They show constitutive spontaneous activity in calcium imaging, which completely depends on extracellular calcium. Stimulation with carbachol and ATP-evoked intracellular calcium transients also depend on extracellular calcium. The intensive coupling between the cells is significantly diminished by incubation with TGF-beta 1. Myofibroblasts form an important cellular element within the afferent signalling of the urinary bladder. They possess all features required to take part in the complex interactions with urothelial cells and sensory nerves. Modulation of their function by cytokines may provide a pathomechanism for bladder dysfunction.

[Structure and function of suburothelial myofibroblasts in the human urinary bladder under normal and pathological conditions]. / Struktur und Funktion der suburothelialen Myofibroblasten in der humanen Harnblase unter normalen und pathologischen Bedingungen.

BACKGROUND: Myofibroblasts play a pivotal role in numerous pathological alterations. Clarification of the structure and function and of the cellular plasticity of this cell type in the bladder may lead to new insights into the pathogenesis of lower urinary tract disorders. PATIENTS AND METHODS: Bladder biopsies from patients with bladder carcinoma and interstitial cystitis were used to analyse the morphology and receptor expression using confocal immunofluorescence and electron microscopy. Cytokine effects and coupling behavior were tested in cultured myofibroblasts and detrusor smooth muscle cells. RESULTS: Myofibroblasts are in close contact with the suburothelial capillary network. They express Cx43 and form functional syncytia. The expression of muscarinic and purinergic receptors is highly variable. Dye coupling experiments showed differences to detrusor myocytes. CONCLUSIONS: Upregulation of smooth muscle cell alpha-actin and/or transdifferentiation into smooth muscle cells may contribute to the etiology of urge incontinence. A multi-step model is presented as a working hypothesis.

[New methods of patient selection for improved anticholinergic therapy]. / Neue Verfahren der optimalen Patientenselektion für die anticholinerge Therapie.

BACKGROUND: M3-specific inhibitors are currently preferred for anticholinergic therapy of OAB. However, not all of the patients profit from this regimen. This might reflect a heterogeneity of the patient group. The aim of this work is to define subgroups of patients with specific alterations of receptor expression and to profile the receptor expression individually. These receptor profiles might be used for the development of evidence-based "tailored" therapies. PATIENTS AND METHODS: Detrusor probes from bladder carcinoma patients (BCa, n=9 F, n=7 male) and interstitial cystitis patients (IC, n=9 female) were examined using confocal immunofluorescence and PCR. RESULTS: M2, M3, P2X1-3, and H1-3 mRNAs were demonstrated in detrusor tissue. As revealed by immunofluorescence, the M2 receptor expression was significantly higher in female compared to male BCa tissues. In addition, the M2 receptor was further upregulated in IC vs BCa in female detrusor. CONCLUSIONS: IC patients showed specific alterations of their receptor profile. Individual receptor profiles might be used to optimize medicinal therapies.