[One-stage correction of scrotal and perineal hypospadias with buccal mucosa]. / Die einzeitige Korrektur skrotaler und perinealer Hypospadien.

Delayed correction of genital malformations can have a negative influence on the emotional, psychosocial and cognitive development. Early one-stage-correction to give as near-normal an appearance and function as possible is therefore desirable. This can now be realized in most forms of hypospadias. However, in the rare and most severe forms (5-6%; scrotal and perineal forms) this is technically very demanding. It is extremely difficult for a surgeon to accumulate enough relevant experience, so that one-stage correction is performed only by very few. To investigate results with one-step correction, 100 of 163 cases treated up to 2006 were analyzed. Analysis of the first group of 50 consecutive cases operated on between 1996 and 2001 showed a complication/reoperation rate of 22% (11 cases). The 11 children required a total of 18 (36%) corrective surgical interventions. In 42 cases buccal mucosa was used as a tube onlay. In this group one- stage correction was successful in 39 (78%); 4 patients required two operations and 7 three. Children in group II were consecutive patients operated on between 2003 and 2006. In this group there was a reoperation rate of 12% (6 cases, in 1 of which severe lack of skin made one-stage correction technically impossible). In 45 cases buccal mucosa was used for a tube-onlay. Thus, in group II 44 patients (88%) underwent successful one-stage correction and 6 had two operations; none had three. The significantly lower complication rate in group II is presumably due to greater experience of the surgeons. All strictures observed developed at the level of the glans. In no case was buccal mucosa rejected; nor did any strictures develop between urethra and neo-urethra, being reliably prevented by the connection, with an onlay, to the recessed urethral plate. None of the 100 children became a 'hypospadias cripple'; in all cases satisfactory correction was ultimately achieved. This means that with growing experience one-stage correction can be increasingly reliably achieved. This is not a general call for one-stage correction, but an appeal for patients with these most severe forms of hypospadias to be treated only in specialized centers with the aim of allowing experience to accumulate there so that the results become more reliable.

[Urinary tract infections in infants and children -- a consensus on diagnostic, therapy and prophylaxis]. / Harnwegsinfektionen im Säuglings- und Kindesalter. Konsensusempfehlungen zu Diagnostik, Therapie und Prophylaxe.

Urinary tract infections (UTI) are among the most common bacterial infections in infants and children. The early diagnosis of a pyelonephritis and its rapid, calculated antibacterial therapy are decisive for the prognosis. Urogenital anomalies, renal damage and bladder dysfunction may influence the risk of recurrences of UTI and pyelonephritic scarring. Diagnostic strategies therefore should focus on their early recognition. Pediatricians, urologists and infectiologists are cooperating in diagnostic, therapy and prophylaxis of UTI. The aim of the interdisciplinary consensus presented was to work out a concept which may help to manage childhood UTI in daily practice.

A multicenter study of lomefloxacin versus ciprofloxacin in the treatment of complicated urinary tract infections.

Lomefloxacin is a new difluorinated quinolone antimicrobial agent with broad antibacterial activity and a long half-life which allows once-daily dosing. A multicenter, randomized trial was conducted to compare the safety and efficacy of once-daily oral lomefloxacin with twice-daily oral ciprofloxacin in the treatment of complicated urinary tract infections (UTIs). All 203 patients enrolled in the study had significant bacteriuria of - 10(5) colony-forming units/ml (CFU/ml) and clinical signs and symptoms of UTI such as dysuria, frequency, urgency, pain, or hematuria. Patients were randomized to receive either 400 mg lomefloxacin once daily (n = 101) or 250 mg ciprofloxacin twice daily (n = 102). The predominant baseline pathogen isolated from the patients in both groups was Escherichia coli. At the third visit (5-9 days post-treatment), 97.8% of patients in the lomefloxacin group and 96.8% in the ciprofloxacin group showed satisfactory bacteriologic results. Clinical success was achieved in 98.9% of patients in both treatment groups and there were no statistically significant differences between the two groups. Both drug regimens were well tolerated and no patient discontinued treatment due to adverse events. It was concluded that once-daily lemofloxacin was as effective as twice-daily ciprofloxacin in patients with complicated UTIs.

[MR of the urinary tract in pregnancy]. / MR der Harnwege in der Schwangerschaft.

A report on the application of standard 2D-FT MR combined with RARE-MR-Urography in a pregnant woman with right sided abdominal pain, dilated upper urinary tract and possible stone or inflammatory disease. This technique visualised the complete obstructed ureter in relation to the surrounding organs (uterus, vessels), allows precise diagnosis of the cause of the obstruction and avoids ionising radiation.

Nitrofurantoin versus trimethoprim for low-dose long-term prophylaxis in patients with recurrent urinary tract infections. A prospective randomized study.

In a prospective randomized study 38 patients with recurrent urinary tract infections (rUTI) were included to take either 50 mg Nitrofurantoin (n = 19) or 50 mg Trimethoprim (n = 19) as low-dose long-term prophylaxis for half a year. Compliance was checked weekly by Bacillus subtilis spore test strips sent in by mail. The infection rate was reduced from more than three per patient year to 0.01. There were no significant differences between the two groups concerning the recurrence rate (Nitrofurantoin: one rUTI; Trimethoprim: three rUTI) or side effects. Under Nitrofurantoin treatment 3 symptomatic fungal infections occurred. Trimethoprim and Nitrofurantoin are equally suitable for low-dose long-term prophylaxis in rUTI. Surveillance of compliance gives important hints for failure of prophylaxis.

[Modern concepts in the treatment of intersexuality]. / Zum aktuellen Stand der Intersextherapie.

Treatment of intersexuality is demanding and requires experience and interdisciplinary cooperation. Preconditions for normal development and clear gender identification are correct (not emergency) diagnosis and gender assignment and adequate hormonal and surgical treatment. Surgery should be done early (6th to 15th month) as atraumatically as possible with cosmetically and functionally satisfying results. These preconditions are not met consistently, resulting in a 20-25% rate of mistakes in diagnosis and treatment. In experienced centers, feminizing genitoplasty, even of the severest forms, is carried out through a perineal one-stage approach. Masculinization corresponds to surgery for severe hypospadias. The high risk of malignant degeneration requires removal of all inadequate structures such as streak gonads, uterus, and tubes. In 5-alpha deficiency, early gonadectomy and feminization are not recommended since gyneophile behavior can be expected. Late or non-correction is rejected by the majority of psychiatrists. Many problems remain unclear and controversial due to lack of knowledge. In the future they can only be solved through cooperation, documentation, and observation of these individuals over their lifetime.

[Treatment of hypospadias]. / Die Behandlung der Hypospadie.

Treatment of all forms of hypospadias is difficult. Several abnormal components have to be differentiated and corrected in a very tight space, in addition to which the blood supply must be preserved and infection prevented. Technical progress now allows early correction (around the age of 12 months) in a single procedure, using methods that date back to the last century. Cosmetic results are as important as functional ones. The glans should be reconstructed around the neomeatus, and the penile shaft should be straight. Microsurgical techniques, short transurethral urinary diversion and reliable dressings are important. Strategies, the sequences of surgical procedures and a selection of practical methods are presented and discussed.

[Diagnosis and therapy of ectopic ureters and ectopic ureteroceles with double kidneys]. / Diagnostik und Therapie ektoper Harnleiter und ektoper Ureterozelen bei Doppelnieren.

Diagnosis and treatment of ectopic ureters and ectopic ureteroceles with renal duplication is a rewarding challenge for any urologist, requiring specific knowledge, awareness of the anomaly and good surgical technique. The diagnosis is primarily based on the correct interpretion of the medical history and the excretory urogram, irreplaceable by sonography. Confusing details can easily be interpreted when the anomaly is detected, or the patient will be left on a long and frustrating path of medical treatment, diagnostic interventions, possibly leading to psychotherapy. The classical triad: renal duplication, incontinence and normal micturition is rarely helpful in complicated cases, compared to the typical findings on the excretory urogram which sometimes are incomplete or only suggestive but still have the highest diagnostic value. Their recognition usually leads to correct diagnosis and treatment. Modern surgical and anesthesiological techniques allow a one stage approach to correct the anomaly and avoid further complications. However, if the risk is considered to be too high, a two stage approach is justified starting with a heminephrectomy. After this 20% will require further surgical treatment of the bladder, due to complications. Dysplastic and nonvisualizing renal segments should not be preserved nor should dilated, ectopically ending ureters. Minimal surgical interventions, reducing, but not solving the problem (incision of ureteroceles, interpelvic anastomosis) are not recommended in modern urological treatment.

[Diagnosis and therapy of xanthogranulomatous pyelonephritis]. / Diagnostik und Therapie der xanthogranulomatösen Pyelonephritis.

Xanthogranulomatous pyelonephritis (XGP) is a rare, unilateral and multifocal inflammatory response of the kidney against bacterial toxins. In the Department of Urology of the University of Freiburg 6 patients with XGP were observed within 10 years. Despite modern diagnostic procedures differential diagnosis from kidney tumors and other parenchymal kidney diseases remains difficult. Recurrent urinary tract infections, fever, urolithiasis, obstruction and leucocytosis may be indicative of XGP. The diagnosis has to be confirmed by surgical intervention which preferably should preserve functioning renal tissue. The prognosis in general is quite good.

[European Association of Urology guidelines on urinary and male genital tract infections]. / Synoptische Leitlinie der sexuell übertragbaren Erkrankungen (STD) mit Primärsymptomen im männlichen Genitale (S1). Leitinien der Deutschen Gesellschaft für Urologie.

Today, the classical bacteria that cause venereal diseases, e.g. gonorrhea, syphilis, chancroid and inguinal granuloma, only account for a small proportion of all known sexually transmitted diseases (STDs). Other bacteria and viruses as well as yeasts, protozoa and epizoa must also be regarded as causative organisms of STD. Taken together, all sexually transmitted infections comprise more than 30 relevant STD pathogens. However, not all pathogens that can be sexually transmitted manifest diseases in the genitals and not all infections of the genitals are exclusively sexually transmitted. Concise information and tables summarising the diagnostic and therapeutic management of STDs in the field of urology allow a synoptic overview, and are in agreement with the recent international guidelines of other specialist areas. Special considerations (i.e. HIV infection, pregnancy, infants, allergy) and recommended regimens are presented.

Development of nosocomial and iatrogenic urinary tract infections (UTI) following urological interventions. A prospective clinical study.

Development of nosocomial and iatrogenic UTI was investigated over 3 months period of time. Included were 140 patients following 228 instrumentations or endoscopical or surgical interventions. Of these 84 were carried out under antimicrobial medication. 30 UTIs developed 1-8 days after the various procedures (= 13.2%): 10% after TUR-B, 14% after TUR-P and ureteral instrumentation, 16% following cystoscopy and catheterisation. No significant difference was observed between: Males and females, patients with or without antimicrobial medication, younger and older patients and after long or short procedures. Indwelling catheters remain sterile for 3 days. Though antimicrobial prophylaxis did not significantly influence the generally low rate of infection it appeared as a trend that the elderly patient who requires repeated interventions and who suffers from additional diseases as diabetes, consuming tumours and renal insufficiency may benefit from medication.

[Medical and legal aspects of treating ambiguous genitalia]. / Medizinische und juristische Aspekte zur Behandlung intersexueller Differenzierungsstörungen.

Treatment of ambiguous genitalia has reached high standards. Damage caused by the anomaly can be reduced significantly or eliminated. In a well-defined minority definite early sex assignment is not possible but preliminary, and surgical genital correction therefore is delayed. Poor results and continuous misunderstandings regarding the nature of intersex caused strong opposition from activist groups against all forms of early diagnosis, sex assignment and surgical treatment. Supported by psychologists and the media, jurisdictional actions are underway trying to change the law and prevent parents from allowing treatment of their children. In addition, institution of a moratorium has been requested to stop genital surgery on children and to establish a third sex of hermaphrodites. All this led to irritations and insecurity concerning treatment and legal risk.Analysis of the current medical situation and the laws concerning the subject reveal that there is no alternative to early sex assignment and treatment, with the exemption of a very small, but defined group. At this moment, there is no realistic legal possibility to remove the right from parents to decide for their children, create a new sex and solve problems of intersex patients by pushing them into"hermaphroditism". This would be a decision against their and their parents' will, in a society which is based on male and female gender.

[Lipoid A, a factor in the pathogenesis of chronic pyelonephritis. Experimental and clinical studies of a lipoid A dependent pathological immune reaction]. / Lipoid A, ein Faktor in der Pathogenese der chronischen Pyelonephritis. Experimentelle und klinische Untersuchungen einer Lipoid A-abhängigen pathologischen Immunreaktion.

Lipid A injected into the temporarily occluded renal pelvis of adult dogs, persisted in the kidney tissue and induced an abacterial interstitial nephritis with positive anti-lipid A titers. This reaction was increased by a single dose of lipid A vaccine, reduced by four consecutive immunisations prior to the lipid A injection and absent in puppies. The presence of IgG, IgM and complement complexes in the kidney was demonstrated by immunofluoroscopy. Lipid A antibody titers were measured by the passive hemolysis test in 349 humans. In two out of 20 healthy adults and 16 out of 18 children with recurrent urinary tract infection anti-lipid A antibodies were present. In contrast, no titers were found in 23 newborn babies. In a group of 156 patients with acute urinary tract infection, 28% revealed positive titers, whereas in a group of 132 patients with recurrent urinary tract infection titers occurred in 81%. Selected from this group of 132 patients 61 suffered from an acute infection of the upper tract. 59 oft these (96%) showed definite titers. There was no difference in the development of anti-lipid A antibodies between men and women and the height of the titers did not correlate with the clinical picture of the disease (acute or chronic). The combination of proteinuria and anti-lipid A antibodies indicates the pressure of reccurrent urinary tract infection or chronic pyelonephritis with about 90% accuracy. The titers are caused by immunogenically active lipid A in the body. Since lipid A has the ability to remain in the renal tissue for a long period of time and thereby to maintain the inflammatory response, long-term antimicrobial prophylaxis (six months) should be given to patients with a high risk of recurrent urinary tract infection.

[Clinical studies of the efficacy and tolerance of cefotaxime, ceftizoxime and ceftriaxone in patients with complicated urinary tract infections]. / Klinische Studie zur Prüfung der Wirksamkeit und Verträglichkeit von Cefotaxim, Ceftizoxim und Ceftriaxon bei Patienten mit komplizierten Harnwegsinfektionen.

An open randomised clinical study was performed in three groups of 20 patients each with well-defined complicated urinary tract infections to compare the efficacy and tolerance of cefotaxime (1-2 g b.i.d.), ceftizoxime (2 g b.i.d.) and ceftriaxone (2 g u.i.d.). Treatment was administered intravenously over seven days. 63% of the patients were free of infection three to five days after the treatment. There was no significant difference in the efficacy of the three antibiotics with respect to the elimination rate of the sensitive bacteria. There were differences, however, with respect to the development of resistance and the occurrence of superinfections during therapy. No resistance developed during therapy in the ceftizoxime group. Resistance developed twice in the cefotaxime group and three times in the ceftriaxone group. Superinfections with resistant bacteria occurred significantly more frequently in the cefotaxime group (n = 8) than in the ceftriaxone group (n = 2). Six superinfections were observed in the ceftizoxime group. These differences, which could not be explained by the presence of complicating clinical factors, were considered to be due to the pharmacokinetic properties of the substances.

[Ceftizoxime concentration in blood, muscle, and kidney tissue]. / Konzentrationen von Ceftizoxim in Serum, Muskel- und Nierengewebe.

The pharmacokinetic properties of ceftizoxime, a new beta-lactamase-resistant cephalosporin, were investigated in 27 patients following perioperative antimicrobial prophylaxis. 2 g of ceftizoxime were injected before surgery and the concentrations measured in serum, muscle and renal tissue over a period of 30 min to 7 h. The pharmacokinetic data indicated high and long-lasting concentrations of ceftizoxime, especially in the renal tissue; this makes the drug ideal for the treatment of complicated urinary tract infections with obstruction and involvement of the renal tissue, provided the bacteria present are sensitive. The administration of 2 g i. v. every 12 h should be sufficient. In view of the high and long-lasting concentrations, it should be possible to treat uncomplicated urinary tract infections with a single dose of 2 g every 24 h. However, Enterococci, Bacteroides and Pseudomonas aeruginosa are not sufficiently sensitive to ceftizoxime and a combination with an aminoglycoside is thus indicated in the treatment of high-risk patients in the absence of bacteriological tests.

Clinical evaluation of Timentin in complicated urinary tract infections.

Timentin proved to be highly effective in the treatment of 70 urological patients suffering from complicated urinary tract infections. There were few adverse effects, and development of resistance was not observed. Surgical treatment was possible in each case, without any septic complications. The results show that Timentin is a very useful drug for the urologist who often treats complicated urinary tract infections, especially because of its low re- and super-infection rate and the absence of development of resistance.

Penile ossification and acquired penile deviation.

We report on 3 patients with penile deviation during erection caused by ossification in the corpora cavernosa. In each case hard plaques could be palpated. These indurations were removed through a dorsal longitudinal incision. Histologically, solid bone was demonstrable. Two patients were able to resume normal sexual intercourse, but one became impotent following postoperative cavernitis. Penile ossification is rare in man, and its etiology is unknown. It bears no relationship to the os penis normally present in many other mammals. Diagnosis is best made by palpation and X-ray examination. The treatment of choice for symptomatic ossification is surgical excision.

[Clinical study of the effectiveness and tolerance of norfloxacin in the therapy of complicated urinary tract infections and in long-term prevention of recurrent urinary tract infections]. / Klinische Prüfung der Effektivität und Verträglichkeit von Norfloxacin in der Therapie komplizierter Harnwegsinfektionen und in der Langzeitprophylaxe rezidivierender Harnwegsinfektionen.

The efficacy and tolerance of norfloxacin in the treatment of complicated urinary tract infections and in low dose long-term prophylaxis over six months for recurrent UTI were investigated in 60 and 27 patients, respectively. In the prophylaxis group, compliance with medication was controlled weekly using Mecur BT. Five to nine days after treatment, the urine was sterile in 50 out of the 60 patients treated (83.3%); relapse occurred in six patients and was associated with development of resistance in two. Four patients suffered re-infection within the study period. Failure of treatment was closely related to persisting complicating factors in the urinary tract. The overall tolerance of norfloxacin was satisfactory. However, there was one severe allergic reaction. During the total 391 weeks of low dose long-term prophylaxis given to 27 patients, only one break-through infection occurred. Yet compliance studies proved that antimicrobial activity was present in the urines of less than 50% of the patients. During prophylaxis, the rate of infection was reduced from three to four to 0.13 to 0.05 infections/patient/year. There was no development of resistance in the isolates from these patients. Only two adverse reactions were observed.

[Efficacy and tolerance of trimethoprim/sulfamethoxazole administered intramuscularly in patients with urinary tract infections (author's transl)]. / Wirksamkeit und Verträglichkeit der intramuskulären Darreichungsform von Trimethoprim/Sulfamethoxazol bei Patienten mit Harnwegsinfektionen.

The antimicrobial efficacy, general and local tolerance of a new intramuscular application form of trimethoprim/sulfamethoxazole was evaluated in a French-German clinical study. Fifty-five urological patients with urinary tract infections were treated with two i. m. injections (3 ml) daily over three to five days followed by oral medication. The study revealed excellent antimicrobial efficacy of the drug. In general TMP/SMZ was tolerated well after i. m. administration. Elevation of creatinine phosphokinase was observed in only three patients treated i. m. for five days. The high viscosity of the solution renders i. m. injection technically difficult, leading to a high proportion of local complications. The indications for use of i. m. administered TMP/SMZ in the hospital are limited, however it should be suitable for private practitioners in that an effective antimicrobial treatment can be started which can be continued by oral or intravenous medication.