Apparent diffusion coefficient values obtained by unenhanced MRI predicts disease-specific survival in bladder cancer.

AIM: To assess the ability of apparent diffusion coefficient (ADC) measurements obtained by MRI to predict disease-specific survival (DSS) in patients with bladder cancer and compare it with established clinico-pathological prognostic factors. MATERIAL AND METHODS: The ethical review board approved this cross-sectional study. Patients with suspected bladder cancer receiving diagnostic 3 T diffusion-weighted imaging (DWI) of the bladder before transurethral resection of the bladder (TUR-B) or radical cystectomy were evaluated prospectively. Two independent radiologists measured ADC values in bladder cancer lesions in regions of interest. Associations between ADC values and pathological features with DSS were tested statistically. A combined model was established using artificial neuronal network (ANN) methodology. RESULTS: A total of 51 patients (median age 69 years, range 41-89 years) were included. Three patients were lost to follow-up, leaving 48 patients for survival analysis. Seven patients died during the 795 months studied. ADC showed significant potential to predict DSS (p<0.05). Except for grading, all pathological features as assessed by TUR-B could predict DSS (p<0.05, respectively). The combined ANN classifier showed the highest accuracy to predict DSS (0.889, 95% confidence interval: 0.732-1, p=0.001) compared to all single parameters. ADC was the second important predictor of the ANN. CONCLUSIONS: ADC measurements obtained by unenhanced MRI predicts DSS in bladder cancer patients. A combined classifier including ADC and clinico-pathological information showed high accuracy to identify patients at high risk for disease-related death.

The use of mannitol in partial and live donor nephrectomy: an international survey.

PURPOSE: Animal studies have shown the potential benefits of mannitol as renoprotective during warm ischemia; it may have antioxidant and anti-inflammatory properties and is sometimes used during partial nephrectomy (PN) and live donor nephrectomy (LDN). Despite this, a prospective study on mannitol has never been performed. The aim of this study is to document patterns of mannitol use during PN and LDN. MATERIALS AND METHODS: A survey on the use of mannitol during PN and LDN was sent to 92 high surgical volume urological centers. Questions included use of mannitol, indications for use, physician responsible for administration, dosage, timing and other renoprotective measures. RESULTS: Mannitol was used in 78 and 64 % of centers performing PN and LDN, respectively. The indication for use was as antioxidant (21 %), as diuretic (5 %) and as a combination of the two (74 %). For PN, the most common dosages were 12.5 g (30 %) and 25 g (49 %). For LDN, the most common doses were 12.5 g (36.3 %) and 25 g (63.7 %). Overall, 83 % of centers utilized mannitol, and two (percent or centers??) utilized furosemide for renoprotection. CONCLUSIONS: A large majority of high-volume centers performing PN and LDN use mannitol for renoprotection. Since there are no data proving its value nor standardized indication and usage, this survey may provide information for a randomized prospective study.

[Energy ablative therapy of renal tumours]. / Energieablative Therapie von Nierentumoren.

Solid renal tumours with a diameter <4 cm may be effectively cured by partial nephrectomy but this is associated with a complication rate of 15-20%. In addition, these tumours are more frequently diagnosed in the elderly (<70 years) and 26% are aggressive G3 and potentially hazardous tumours. Since these tumours are frequently unifocal, spherical, peripherally located and easily accessible for minimally invasive approaches, energy ablative techniques are attractive less invasive therapeutic options. These tumours may be treated by freezing (cryoablation) or by heat (radiofrequency ablation, high intensified focused ultrasound). Cryoablation seems to be the most reliable technique with a 1.6% recurrence rate over 3 years follow-up but only 1.8% complications. Conversely skipping renders RFA unreliable in highly vascularised tumours >3 cm with 23% vital tumours to be found at histological work-up. Laparoscopic HIFU is still experimental. Percutaneous techniques are less effective as compared with laparoscopy with recurrence rates ranging between 13-21% (cryoablation) and 14-18% (RFA). In addition, oncological follow-up relies solely on radiological measurements, frequently without histological verification thus making percutaneous techniques unpredictable.

Local intratumoral tumor necrosis factor-alpha and systemic IFN-alpha 2b in patients with locally advanced prostate cancer.

To examine tolerability and activity of local, intratumoral tumor necrosis factor-alpha (TNF-alpha) and systemic interferon-alpha2b (IFN-alpha2b) in locally advanced, hormone-resistant prostate cancer (LA-HRPC), 10 patients with LA-HRPC (T4N x M0, n = 3, T4N x M1, n = 5; T4N1M1, n = 2) were treated with recombinant TNF-alpha injected locally into prostate tumor tissue at 4-week intervals (maximum of four cycles) combined with intermittent subcutaneous (s.c.) administration of 5 x 10(6) IU IFN-alpha2b. Twenty-nine TNF-alpha cycles were administered. Despite significant TNF-alpha leakage into the systemic circulation 2 h after intraprostatic application (from a mean of 9 to a mean of 416 pg/ml; p = 0.0034), TNF-alpha (and IFN-alpha2b) was well tolerated (WHO grade 1-2 toxicity), possibly because of its rapid neutralization by increasing soluble 55-kDa and 75-kDa TNF receptor levels in the serum (mean increase 268% and 91%, respectively) at the same time. TNF-alpha induced prostate tumor cell necrosis in all patients, leading to a significant reduction of prostate volume in 9 of 10 cases (mean 38%; p = 0.0025). The significant short-term increase of prostate-specific antigen (PSA) (mean 65%; p < 0.001), tissue polypeptide-specific antigen (TPS) (mean 85%; p = 0.001), and possibly interleukin-8 (IL-8) (mean 2687%; p < 0.009) serum levels within 4 h after TNF-alpha confirmed the cytotoxic effect in vivo. In the long term, serum PSA levels dropped by 18%-87%, reaching the nadir value 7 weeks after baseline. Objective responses of metastases were not seen. Intraprostatic administration of TNF-alpha is feasible at a tolerable toxicity in patients with LA-HRPC and, thus, may be a new treatment option for these patients.

Serum dehydroepiandrosterone sulfate concentrations in men with erectile dysfunction.

OBJECTIVES: In 1994, the Massachusetts Male Aging Study presented the finding of an inverse correlation of the serum levels of dehydroepiandrosterone sulfate (DHEAS) and the incidence of erectile dysfunction (ED). Prompted by the positive results of a pilot study on the treatment of ED with dehydroepiandrosterone (DHEA), we performed a detailed investigation on the serum DHEAS levels in men with ED according to age category. METHODS: Inclusion criteria included a history of ED for more than 6 months, a body mass index less than 30, and a state of good general health. Serum DHEAS concentrations were determined in 309 patients with ED and 133 healthy volunteers. All participants were carefully screened to assess medical factors known or suspected to alter endocrine function. Questions 3 and 4 of the International Index of Erectile Function were used to evaluate erectile function. RESULTS: The mean serum levels of DHEAS in patients with ED were lower than in healthy volunteers until 60 years of age. The shape of the curve of the patients with ED indicated a quadratic decrease of DHEAS with age in contrast to a more linear decrease of DHEAS with age in the control group. CONCLUSIONS: Our results suggest that until the age of 60 years, the mean serum level of DHEAS is lower in patients with ED than in healthy volunteers.

[Submucous mucous membrane support in intrinsic sphincter insufficiency. A therapeutic approach in female stress incontinence]. / Submuköse Schleimhautunterfütterung bei intrinsischer Sphinkterinsuffizienz. Ein Therapieanatz bei weiblicher Stressinkontinenz.

Urethral bulking agents are an attractive alternative for treating patients with intrinsic sphincter deficiency (ISD), i.e., type III urinary stress incontinence. These endoscopic techniques are minimally invasive and can be used in high-risk patients. As bulking agents, Teflon, autologous fat, collagen, silicone particles, and detachable microballoons have been the object of considerable clinical research. Teflon forms granulomas in the surrounding tissue and tends to migrate and is now considered obsolete. More recently, human collagen, autologous cartilage, Bioglass, and hyaluronic acid with dextranomer and polycarbon particles have come under clinical investigation, but long-term results are still lacking. The optimal bulking agent should be nondegradable and biologically inert and should not migrate or change its bulking capability. To date, there is no consensus on the best agent fulfilling these requirements, but encapsulated substances appear most promising.

Magnetic resonance imaging-guided prostate biopsy: institutional analysis and systematic review.

OBJECTIVES: To evaluate the detection rate of prostate cancer (PCa) after magnetic resonance-guided biopsy (MRGB); to monitor the patient cohort with negative MRGB results and to compare our own results with other reports in the current literature. MATERIALS AND METHODS: A group of 41 patients was included in this IRB-approved study and subjected to combined MRI and MRGB. MRGB was performed in a closed 1.5 T MR unit and the needle was inserted rectally. The follow-up period ranged between 12 and 62 months (mean 3.1 years). To compare the results with the literature, a systematic literature search was performed. Eighteen publications were evaluated. RESULTS: The cancer-suspicious regions were punctured successfully in all cases. PCa was detected in eleven patients (26.9 %) who were all clinically significant. MRGB showed a benign histology in the remaining 30 patients. In the follow-up (mean 3.1 years) of patients with benign histology, no new PCa was diagnosed. The missed cancer rate during follow-up was 0.0 % in our study. CONCLUSION: MRGB is effective for the detection of clinically significant cancer, and this is in accordance with the recent literature. In the follow-up of patients with benign histology, no new PCa was discovered. Although the probability of developing PCa after negative MRGB is very low, active surveillance is reasonable.

Utility and limitations of 3-Tesla diffusion-weighted magnetic resonance imaging for differentiation of renal tumors.

OBJECTIVE: To investigate utility and limitations of 3-Tesla diffusion-weighted (DW) magnetic resonance imaging (MRI) for differentiation of benign versus malignant renal lesions and renal cell carcinoma (RCC) subtypes. MATERIALS AND METHODS: Sixty patients with 71 renal lesions underwent 3 Tesla DW-MRI of the kidney before diagnostic tissue confirmation. The images were retrospectively evaluated blinded to histology. Single-shot echo-planar imaging was used as the DW imaging technique. Apparent diffusion coefficient (ADC) values were measured and compared with histopathological characteristics. RESULTS: There were 54 malignant and 17 benign lesions, 46 lesions being small renal masses ≤ 4 cm. Papillary RCC lesions had lower ADC values (p=0.029) than other RCC subtypes (clear cell or chromophobe). Diagnostic accuracy of DW-MRI for differentiation of papillary from non-papillary RCC was 70.3% resulting in a sensitivity and specificity of 64.3% (95% CI, 35.1-87.2) and 77.1 (95% CI, 59.9-89.6%). Accuracy increased to 83.7% in small renal masses (≤ 4 cm diameter) and sensitivity and specificity were 75.0% and 88.5%, respectively. The ADC values did not differ significantly between benign and malignant renal lesions (p=0.45). CONCLUSIONS: DW-MRI seems to distinguish between papillary and other subtypes of RCCs especially in small renal masses but could not differentiate between benign and malignant renal lesions. Therefore, the use of DW-MRI for preoperative differentiation of renal lesions is limited.

Morbidity of laparoscopic extraperitoneal versus transperitoneal radical prostatectomy verus open retropubic radical prostatectomy.

OBJECTIVE: Morbidity and postoperative pain after extraperitoneal (E-LRPE) and transperitoneal (T-LRPE) laparoscopic radical prostatectomy was compared to open extraperitoneal radical prostatectomy (O-RPE). MATERIAL AND METHODS: Between January 2002 and October 2003, we evaluated 41 E-LRPE, 39 T-LRPE and 41 O-RPE prospectively. All operations were performed as standard procedures by the same group of surgeons and perioperative results and complications were evaluated. Pain management was performed with tramadol 50-100 mg on demand, and no other form of anaesthesia was given. Postoperative pain was assessed daily in all patients quantifying analgesic requirement and evaluation of Visual Analogue Scale (VAS). All patients had at least a 12 month follow-up. RESULTS: Mean age, prostate volume, PSA and Gleason score were comparable between all three groups (p>0.05). Mean blood loss was lower with laparoscopy (189+/-140 and 290+/-254 ml), as compared to 385+/-410 ml for O-RPE (p=0.002). However, mean operating times were significantly longer in L-TRPE (279+/-70 min) as compared to E-LRPE (217+/-51 min) and O-RPE (195+/-72 min) (p<0.001), but E-LRPE and O-RPE showed no statistical difference (p=0.1143). Average VAS score on the 1st and 5th postoperative day for E-LRPE versus T-LRPE versus O-RPE was 4.9+/-1.0 versus 7.8+/-1.5 versus 5.8+/-1.9 and 1.6+/-0.9 versus 2.3+/-1.2 versus 2.3+/-0.9 respectively, which was significant lower (p=0.02) between E-LRPE versus T-LRPE (p<0.001) and O-RPE (p=0.008), but equal (p=0.655) between T-LRPE and O-RPE since postoperative day 3. Mean tramadol analgesic consumption within the first postoperative week was 290 versus 490 versus 300 mg respectively, which was statistical different between E-LRPE and T-LRPE (p<0.001), O-RPE and T-LRPE (p<0.001), but not between E-LRPE and O-RPE (p=0.550). Statistical analysis revealed a strong correlation of urinary leakage with increased postoperative pain (p=0.029) in all groups, especially for T-LRPE (p=0.007). Likewise, increased operating times (>240 min) were associated with increased post-operative pain (p=0.049). Full continence defined as no pads at one year was achieved in 36/41 (88%, E-LRPE) versus 33/39 (85%, T-LRPE) versus 33/41 (81%, O-RPE), respectively (p=0.2). CONCLUSION: E-LRPE resulted in a significant subjective (VAS Score, p<0.001) and objective (analgetic consumption, p<0.001) pain reduction compared to T-LRPE, but only in VAS Score compared to O-RPE (p=0.008). Analgetic consumption during first postoperative week was equal in E-LRPE (290 mg) and O-RPE (300 mg) (p=0.550). Shorter operating times, lower urinary leakage rates, lower stricture rates and lower blood loss in E-LRPE compared to T-LRPE are mainly explained due to the long learning curve in LRPE, which we did not overcome yet, and not due to the approach (extraperitoneal versus transperitoneal).

Use of peripheral neuromodulation of the S3 region for treatment of detrusor overactivity: a urodynamic-based study.

OBJECTIVES: To determine the efficacy of peripheral neuromodulation of the S3 region in patients with urgency-frequency syndrome due to an overactive bladder. METHODS: Fifteen patients (11 women and 4 men) with urgency-frequency syndrome, as documented by a voiding chart, were diagnosed with overactive bladder. Pelvic pain was assessed by a visual analogue scale (VAS). Full urodynamic workup was performed before and after 12 peripheral stimulations with a 9-V monopolar generator, the so-called Stoller Afferent Nerve Stimulator (SANS). Follow-up was for a mean (SD) of 10.9 (4 to 15) months. RESULTS: Reduction in pain was achieved in all patients, with a decrease in VAS from a mean (SD) of 7.6 (5 to 10) to 3.1 (1 to 7) (P = 0.00049). Seven patients (46.7%) had a complete response and were considered cured, 3 (20.0%) showed significant improvement, and 5 (33.3%) were classified as nonresponders. Urodynamic evidence of bladder instability, evident in all patients before treatment, was eliminated in 76.9% of patients. In all patients, mean (SD) total bladder capacity increased significantly from 197 (35 to 349) to 252 (78 to 384) mL (P = 0.00795), mean (SD) volume at first bladder sensation from 95 (16 to 174) to 133 (32 to 214) mL (P = 0.00166), and mean (SD) bladder volume at normal desire to void from 133 (27 to 217) to 188 (47 to 296) mL (P = 0.00232). In the responding group, the mean (SD) total numbers of voids was reduced from 16.1 (9 to 24) times during the day and 4.4 (2 to 6) times during the night to 8.3 (6 to 10) and 1.4 (1 to 2) times (P = 0.002539), respectively. No complications from treatment were observed. CONCLUSIONS: Peripheral neuromodulation of the S3 region can successfully treat patients with urgency-frequency syndrome due to an overactive bladder.

Incidence of antisperm antibodies in patients with carcinoma of the testis and in subfertile men with normogonadotropic oligoasthenoteratozoospermia.

The incidence and the clinical relevance of sperm-reactive antibodies in subfertile men and in testicular cancer patients were assessed in a pilot study. The sera of 42 men with normogonadotropic oligoasthenoteratozoospermia (OAT syndrome, n = 20) or carcinoma of the testis after inguinal semicastration (n = 22) were analyzed for agglutinating antisperm antibodies using fluorescein-labeled antiglobulin. In the group with the OAT syndrome, the incidence of sperm-reactive antibodies was only 5%, which is comparable to that in normal fertile men. Although the incidence of 18% in the testicular cancer patients was markedly higher, only 2 of the patients in question had abnormal spermiograms, which in one case could, moreover, be explained by previous radiation therapy. In summary in this small group of patients, serum monitoring for sperm-reactive antibodies appeared to be of limited clinical relevance in patients with the OAT syndrome and in testicular cancer patients.

Urolithiasis in allograft kidneys.

OBJECTIVES: Allograft stones are an uncommon clinical problem and management is mainly based on anecdotal experience, rather than analysis of larger series. METHODS: In an 8-year period, 19 patients were treated for 19 renal and 3 ureteral stones. In 9 patients, stones were transplanted and 10 formed de novo stones within a mean of 28 months (range 13 to 48) after transplantation. In 4 patients, stones were removed during transplantation. Seven patients were treated with extracorporeal shock wave lithotripsy (ESWL), 3 patients had stones removed percutaneously, 1 by antegrade ureteroscopy, and 1 at the time of ureteral reimplantation. Three patients passed stones spontaneously. RESULTS: In 3 of 4 patients with stones detected before transplantation, the procedure was completed successfully after endoscopic stone removal. Three of 5 patients with transplanted stones required emergency nephrostomy; 1 patient had permanent renal impairment. Three (42.9%) of 7 patients treated with ESWL needed transient nephrostomy; ultimately, all became stone free within a mean 15 days (range 10 to 40). Endoscopic stone removal always resulted in complete clearance without renal impairment. All patients were stone free during a follow-up of 29 months (range 13 to 48). CONCLUSIONS: Nine (47%) of 19 stones were actually transplanted. Therefore, intraoperative screening by ultrasonography with subsequent endoscopic removal is advisable. Small stones (4 mm or less) may be closely followed up, because they can pass spontaneously. ESWL is the treatment of choice for caliceal stones sized 5 to 15 mm. However, for stones greater than 15 mm or for ureteral stones, antegrade endoscopic procedures seem to be more favorable.

Value of routine sonography in the diagnosis and conservative management of renal angiomyolipoma.

A prospective study was undertaken to assess the value of ultrasonography in the clinical monitoring of angiomyolipomas. 26 patients with angiomyolipomas as diagnosed by sonography and verified by computerized tomography (CT) were followed up by sonographic monitoring over a mean period of 45 months. One case was associated with tuberous sclerosis. Inclusion criteria for conservative management had been clinically asymptomatic angiomyolipomas smaller than 5 cm. Significant tumor growth and a change of the sonographic pattern during follow-up was seen in 2 patients. After renewed follow-up CT scanning failed to reveal negative density values, both patients were nephrectomized. Histologic examination showed hemorrhage in the tumor. The remaining 24 patients (92%) showed no changes in the sonographic patterns. Minor tumor growth of 0.5 cm on average was seen in 6 patients over a mean follow-up period of 52 months. Surgical intervention was refrained from in these 24 patients due to the consistent sonographic pattern and the absence of clinical symptoms. Once the angiomyolipoma is verified by CT, sonographic monitoring suffices if the sonostructure remains unchanged. Minor asymptomatic angiomyolipomas today no longer require surgical intervention as this benign tumor has a pathognomonic sonographic appearance.

Sonographic appearance of testicular microlithiasis.

Testicular microlithiasis was sonographically diagnosed in 16 patients. Using high-frequency transducers, the typical speckled pattern with multiple small bright echoes generated by intratubular calcifications appeared in the sonograms. The finding was bilateral in all but one patient who had previously undergone semicastration for testicular cancer and subsequent irradiation. In 6 cases a testicular tumor was present and visible in the sonogram. Sonography was performed in another 6 cases because of varicocele or epididymal cysts. The spermiograms and tumor marker levels of these patients were within the normal range, and there was no evidence of an extragonadal germinal tumor. Three patients presented with oligozoospermia, 1 thereof with hypogonadism. In 7 cases the sonographic diagnosis was histologically confirmed, i.e. multiple calcifications were found within the seminiferous tubules. The etiology and clinical significance of this rare phenomenon are unclear. Testicular microlithiasis is asymptomatic and also found in otherwise normal testes. However, in contrast to normal testes, a high percentage of testicular tumors is known to be associated with microcalcifications. In the presence of a definite sonographic diagnosis, exclusion of malignancy and sonographic follow-up are therefore indicated, as in the present series 44% of cases presented with testicular tumors.

Benefits of laparoscopic renal surgery are more pronounced in patients with a high body mass index.

PURPOSE: Aim of this prospective study was to determine whether patients with a higher body mass index (BMI) will benefit more from laparoscopic procedures in respect to postoperative morbidity and pain as compared to regular patients. PATIENTS AND METHODS: Between September 1999 and October 2001, we performed 36 laparoscopic radical nephrectomies and 18 nephron sparing partial nephrectomies for renal cell carcinoma and 6 nephrectomies for benign disease (group 1, n=60). In addition, we performed 24 open radical nephrectomies and 18 nephron spearing interventions for renal cell carcinoma (group 2, n=42). Mean age was 59+/-17.9 years and average BMI was 27.1+/-3.3 kg/m(2) in the entire group. All techniques were evaluated for intraoperative results and complications. Postoperative morbidity was assessed in all patients by quantifying pain medication and by daily evaluation of Visual Analogue Scale (VAS). RESULTS: Mean hospitalisation time in group 1 as compared to group 2 was 10.1 days versus 5.4 days, average operating time was 273 minutes versus 187 minutes, mean length of skin incision was 7.2 cm versus 30.8 cm. Overall analgesic consumption was lower in the laparoscopic group (190 mg versus 590 mg, p<0.001), in patients with a BMI >28 kg/m(2) the difference was even more pronounced (160 mg versus 210 mg, p=0.032). In group 1, patients with a BMI >28 kg/m(2) had significantly less pain on the first and fourth postoperative day in a linear regression analysis (VAS1=10.714-0.218 BMI; r=0.688 (p<0.001) and VAS4=3.98-0.09 BMI, r=0.519 (p<0.001), respectively). In group 1, 3/60 (5.0%) and in group 2, 5/42 (11.9%) complications occurred, no difference was found in respect to a high BMI (p=0.411). CONCLUSION: Patients with a higher BMI (cut-off >28 kg/m(2)) benefit more from laparoscopy than slim patients in respect to postoperative pain and morbidity but do not experience more complications. Consequently, reluctance to perform laparoscopic procedures in patients with a higher BMI is no longer justified.

Impact of different sized catheters on pressure-flow studies in patients with benign prostatic hyperplasia.

The importance of pressure-flow studies for the diagnostic work-up of patients suffering from benign prostatic hyperplasia (BPH) has recently been recognized more widely. For these studies, several different types and sizes of catheters have been used. According to our experience, the degree of obstruction seems to be dependent on the catheter size applied. To evaluate the impact of catheter size on urodynamic results, 64 male patients underwent pressure-flow studies; 41 had the clinical diagnosis BPH; 23 were a nonobstructed control group. The 41 BPH-patients were randomized into two groups: group BPH 1 (n = 20) had a 5F catheter and group BPH 2 (n = 21) had a 10F filling catheter in addition to the 5F pressure transmission catheter in the urethra. All patients underwent three filling and pressure-flow studies. The filling catheter was removed for the third pressure-flow study. Peak flow rates (Qmax; ml/s), the corresponding detrusor pressure at maximum uroflow (PdetQmax; cm H2O) and the degree of obstruction, rated according to the linear passive urethral resistance relation (linear-PURR), were assessed. The removal of the 5F (group BPH 1) or 10F (group BPH 2) filling catheter resulted in a 21.1% and 55.7% increase of maximum uroflow rate respectively. In parallel, we observed a 9.9% and 18.8% decrease of detrusor pressure at maximum flow. The degree of obstruction classified according to linear-PURR decreased by 14.6% and 21.1% respectively. Furthermore, it became evident that five patients (21.7%) of the unobstructed control group could have been wrongly interpreted as being obstructed if measured with the filling (10F) and the pressure measurement (5F) catheter in situ. In conclusion, the degree of obstruction is dependent on the cross-sectional diameter of the used catheters. Consequently, standardization with regard to catheter size is mandatory if data from different institutions are to be compared.

Role of bacteria in the development of kidney stones.

Currently, only struvite stones are regarded as deriving from bacteria. Recent work has suggested that calcium-based stones might also have an infectious origin. Nanobacteria, small intracellular bacteria found in human kidney stones, are capable of forming a calcium phosphate shell, and thus could serve as crystallization centres for renal calculi formation. Until now, however, all trials performed to confirm the presence of nanobacteria in human calculi, serum or urine have failed. In a hyperoxaluric rat model, tissue-residing macrophages were able to remove interstitial crystals and thus may not be primarily engaged in defending against micro-organisms, if present.

Value of power Doppler sonography in the investigation of erectile dysfunction.

OBJECTIVES: The poor sensitivity of conventional color-coded Doppler sonography (CCD) for low-flow signals limits its use for investigating patients with erectile dysfunction. Power Doppler sonography (PD) has recently been described for enhanced visualization of the microcirculation. Aim of this study was to determine the value of PD to demonstrate penile vascular pathophysiology as compared with conventional techniques. METHODS: 33 consecutive men with erectile dysfunction were investigated using the standard workup with conventional CCD and cavernosography before and after prostaglandin E(1) intracavernosal injection. Patients were subdivided into an arteriogenic, a venogenic, or a psychogenic group according to findings in the standard diagnostic workup. PD was used in addition to the standard protocol to demonstrate microcirculation, arterial blood flow, and venous leakage. The accuracy of the diagnosis obtained by PD and response to intracavernosal injection was compared with the clinical outcome in these groups at 6 months. RESULTS: PD was found to be superior to CCD in visualizing cavernosal microcirculation. In addition, arterial flow at basal peak systolic velocity was demonstrated in all patients with PD, whereas a signal sufficient for evaluation was obtained with CCD in only 69.7% (23/ 33). No significant difference in the maximal peak systolic velocity was noted using either PD or CCD. The positive predictive value of PD for venous leakage was poor (60%) when compared with cavernosography. PD used in conjunction with the response to intracavernosal injection was found to reliably predict the clinical outcome in the arteriogenic (p = 0.0007), the venogenic (p = 0.005), and the psychogenic group (p = 0.0002). CONCLUSIONS: Our data indicate that PD improves the evaluation of penile microcirculation and arterial function, but fails to reliably demonstrate venous leakage alone. Nevertheless, in most patients cavernosography could have been avoided by the aid of PD, since the underlying pathology can be calculated at a high predictive value without the need of further invasive tests. Therefore, with the aid of PD, the morbidity for patients being investigated for erectile dysfunction can be significantly reduced.

Modified laparoscopic nephroureterectomy for treatment of upper urinary tract transitional cell cancer is not associated with an increased risk of tumour recurrence.

INTRODUCTION: Laparoscopic nephroureterectomy reduces the morbidity of surgical management of urinary tract transitional cell carcinoma (TCC), but a potentially increased risk for local tumour spreading was reported. We evaluated results obtained from patients undergoing a modified laparoscopic approach and open procedures in this respect. PATIENTS AND METHODS: Between January 2000 and March 2002 we performed 19 modified laparoscopic nephroureterectomies (LNU) with open intact specimen retrieval in conjunction with open distal ureter and bladder cuff removal and 15 open standard nephroureterectomies (ONU). Staging lymphadenectomy was performed in 14/19 (73.7%) patients with LNU and in 6/15 (40.0%) with ONU. In all patients operating time, blood loss, complications, pain score (VAS) and data in respect to tumour recurrence were analysed. Mean follow-up was 22.1+/-9.2 (range 14-34) months for LNU and 23.1+/-8.8 (14-36) for ONU respectively. RESULTS: In LNU and ONU pathological features were 12 pT1 vs. 10 pT1, 2 pT2 vs. 2 pT2 and 5 pT3 vs. 3 pT3, respectively. All patients had TCC and were R0 at final histology. Four patients with LNU had lymph node involvement, one in ONU. LNU had decreased operating times (p=0.057), blood loss (p=0.018), complications (p=0.001) and VAS scores (p=0.001). One tumour recurrence occurred in LNU, associated with a pT3b pN2 G3 TCC at final histology. One patient with ONU had local tumour recurrence at the site of the bladder cuff. No port-site metastasis occurred during follow-up with LNU. CONCLUSION: Improved peri-operative results and same cancer control as compared to open surgery by this modified LNU was not associated with an increased risk for tumour recurrence, since strict "non-touch" preparation, avoiding of urine spillage and intact specimen retrieval prevents tumour seeding. However, results from long term studies are still warranted to clarify this issue.

Age related urodynamic changes in patients with benign prostatic hyperplasia.

PURPOSE: We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A total of 222 patients (mean age 67.3 years, range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS), prostate volume, noninvasive uroflowmetry, residual volume and a pressure-flow study. To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml. per second or less and an I-PSS of 7 or more were eligible. RESULTS: There was no correlation between age and I-PSS (p > 0.05) but there was a statistically significant decrease in maximum flow rate (p = 0.045) and voided volume (p = 0.0013) with age. Prostate volume increased constantly from 31.3 to 64.4 ml. in patients 45 to 50 and older than 80 years, respectively (p < 0.0001). Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 0.0003) and invasive maximum flow rate (p = 0.0057) but no changes in detrusor pressure at maximum flow rate (p > 0.05), maximum detrusor pressure (p > 0.05) and linear passive urethral resistance relation (p > 0.05). The incidence of urodynamically proved bladder instability increased from 20 to 47% in men 45 to 50 and older than 80 years, respectively. CONCLUSIONS: The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function. Because 60% of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml. per second, all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention.